INSTITUSI LATIHAN KEMENTERIAN KESIHATAN MALAYSIA

SULTAN AZLAN SHAH

ADVANCED DIPLOMA IN EMERGENCY CARE (ADEC)

A STUDY ON KNOWLEDGE OF GLOSCOW COMA SCALE (GCS)

AMONG ADVANCE DIPLOMA EMERGENCY CARE (ADEC) ‘S
STUDENT COHORT 7 IN ILKKM SULTAN AZLAN SHAH

NAME : FARAH ATHIRAH BINTI MOH FUZI

MATRIX NUMBER : ADEC 1/2020 (K)-0173

SUPERVISOR : SIR MOHD RASHEEDI ROMAINOR

DECLARATION

I hereby declare that the work in this research is my own except for
quotations and summaries which have been duly acknowledge.

JUNE 2022 Farah Athirah Binti

Moh Fuzi
ADEC 1/2020 (K) -
0173
 ACKNOWLEDGMENT

All praise and gratitude to the Almighty. With His grace we finally complete
this study despite the many challenges and tribulations endured. First of all, I
would like to take this opportunity to express my appreciation to all friends
from Advance Diploma Emergency Care (Adec) Cohort 7 in Ilkkm Sultan
Azlan Shah for given me many cooperation to complete this study. Million
thanks to my supervisor, Encik Mohd Rasheedi Romainor who always give
me 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.

Besides, Encik Ahmad my research teacher and Encik Tigilan my

coordinator for giving me some valuable advice and tips along the pathway to
completed this study and spends lots of his time to give me guidance. I would
also like to thank my friends Nurul Hanani Abdullah and Nor Suliana Mohd
Razali for giving spirit and advice until completed this study and all classmate
who supported and participate in this study.

The Ethical Committee of ILKKM Sultan Azlan Shah for giving us

permission to conduct this study. I also dedicate this study to my future
husband and family for being my sources of inspiration and give support
when in need.

Last but not least, my sincere thanks to any individuals involved

directly or indirectly in assisting for the success of my research project. May
Allah bless all of you, thank you.
 ABSTRACT

A Study On Knowledge Of Gloscow Coma Scale (Gcs) Among Advance

Diploma Emergency Care (Adec) ‘S Student Cohort 7 In Ilkkm Sultan
Azlan Shah
Farah Athirah Binti Moh Fuzi

Background: Glasgow coma scale (GCS) develop by Taesdale and Jannet

in 1974 at the Institute of Neurological Science, Glasgow, UK. The GCS is
the most common neurological assessment tool and is widely used to
measure arousal and cognition.

Aim: To study about knowledge of Glasgow Coma Scale (GCS) among

student Advance Diploma Emergency Care (ADEC) batch cohort 7 in ILKKM
Sultan Azlan Shah.

Methodology: Quantitative, Descriptive, Cross-Sectional study which

involved 36 participants from ADEC ILKKM Sultan Azlan Shah.
Questionnaire (3 demographic data, 20 questions on knowledge of GCS)
used as instrumental method and data was analysed by SPSS V22.

Result: 63.9%of the respondent had excellent knowledge, 25% had good
knowledge and 11.1% had average knowledge of the GCS. Besides, there is
no significant different between knowledge and profession. There is also no
association between level of knowledge and working experience.

Conclusion: This study demonstrate that majority of the participants had an

excellence knowledge in Glasgow Coma Scale. Continuous education
session, courses and educational programmed for student are
recommended.

Keywords: Glasgow Coma Scale, knowledge of GCS, profession, working

experience.
 ABSTRAK

Latar belakang: Skala koma Glasgow (GCS) dibangunkan oleh Taesdale

dan Jannet pada tahun 1974 di Institut Sains Neurologi, Glasgow, UK. GCS
ialah alat penilaian neurologi yang paling biasa dan digunakan secara
meluas untuk mengukur rangsangan dan kognisi.

Matlamat: Untuk mengkaji tentang pengetahuan Glasgow Coma Scale

(GCS) dalam kalangan pelajar Advance Diploma Emergency Care (ADEC)
kumpulan kohort 7 di ILKKM Sultan Azlan Shah.

Metodologi: Kajian Kuantitatif, Deskriptif, Cross-Sectional yang melibatkan

36 orang peserta daripada ADEC ILKKM Sultan Azlan Shah. Soal selidik (3
data demografi, 20 soalan tentang pengetahuan GCS) digunakan sebagai
kaedah instrumental dan data dianalisis oleh SPSS V22.

Keputusan: 63.9% daripada responden mempunyai pengetahuan yang

sangat baik, 25% mempunyai pengetahuan yang baik dan 11.1%
mempunyai pengetahuan sederhana tentang GCS. Selain itu, tiada
perbezaan yang signifikan antara pengetahuan dan profesion. Juga tiada
perkaitan antara tahap pengetahuan dan pengalaman bekerja.

Kesimpulan: Kajian ini menunjukkan bahawa majoriti peserta mempunyai

pengetahuan kecemerlangan dalam Skala Koma Glasgow. Sesi pendidikan
berterusan, kursus dan program pendidikan untuk pelajar adalah disyorkan.

Kata kunci: Skala Koma Glasgow, pengetahuan tentang GCS, profesion,

pengalaman bekerja.
 TABLE OF CONTENT

TABLE OF CONTENT i

ABBREVIATION iv

CHAPTER 1 INTRODUCTION 1

1.1 Introduction 1

1.2 Background of the study 1

1.3 Problem statement 3

1.4 Research objective 5

1.5 Research hypothesis 6

1.6 Significance of the study 6

1.7 Research scope 7

1.8 Definition of terms 7

1.9 Summary 8

CHAPTER 2 LITERATURE REVIEW 9

2.1 Introduction 9

2.2 Overview on Gloscow Coma Scale (GCS) 9

2.3 Relevant literature to the knowledge of paramedic in gcs 9

2.4 Conceptual Framework 12

2.5 Summary 13

CHAPTER 3 METHODOLOGY 14

3.1 Introduction 14

3.2 Research design 14

3.3 Research setting 14

3.4 Duration for data collection 14

3.5 Population and sampling 15

3.5.1 Population 15

i
 3.5.2 Sample size 15

3.5.3 Sampling 15

3.5.4 Inclusion criteria. 15

3.6 Research instrumentation 16

3.6.1 Variables 16

3.7 Pilot study 17

3.8 Data collection procedure 17

3.8.1 Flowchart for data collection 18

18

3.9 Proposed plan for data analysis 18

3.10 Ethical Considerations 19

3.11 Summary 19

CHAPTER 4 DATA ANALYSIS 20

4.1 Subject demographic 20

4.2 Level of knowledge in Glasgow Coma Scale 21

4.3 The differences of participant’s knowledge in Glasgow

Coma Scale and profession. 21

4.4 The association between the level of knowledge in Glasgow

Coma Scale and working experience. 23

CHAPTER 5 DISCUSSION 24

CHAPTER 6 27

LIMITATION, RECOMMENDATION AND CONCLUSION 27

6.1 INTRODUCTION 27

6.2 LIMITATION 27

6.3 RECOMMENDATION 28

6.4 CONCLUSION 29

REFERENCES 30

APPENDIX 33

ii
iii
 ABBREVIATION

Advance Diploma Emergency Care ADEC

Advanced Life Support ALS

Advanced Trauma Life Support ATLS

Assistant Medical Officer AMO

Glasgow Coma Score GCS

Institut Latihan Kementerian Kesihatan Malaysia ILKKM

Registered Nurse RN

iv
 CHAPTER 1
INTRODUCTION

1.1 Introduction

This chapter will discuss generally about the background of the study,
problem statement, general objective, specific objective, research questions,
significance of the study and operational definition of the study.

1.2 Background of the study

Glasgow Coma Scale (GCS) is a clinical scale used to reliably measure a

person’s level of consciousness. Measuring a patient’s mental health status is
one of the important components in a patient assessment. According to
Teasdale&Jennett (1974) “Assessment of coma and impaired consciousness:
a practical scale.” The GCS was constructed mainly to improve
communication between doctors and paramedic when describing difficult state
of impaired consciousness and to avoid ambiguous definition such as
somnolence. Since 1974, GCS scoring has become the standardized and
widely used tool in patient assessment for level of consciousness, which was
first introduced by neurosurgery professors Graham Teasdale and Bryan
Jennet

The GCS assessed motor, verbal and eye response (Faruq, 2014).
This supported by Catangui (2019), the GCS has three main components
which is eye opening (E), verbal response (V), and motor response (M). The
maximum score is 15 and the minimum is 3. GCS score must be summarized
into score of each component. The maximum score for eye opening is 4,
verbal response is 5 and motor response is 6. Moreover, the GCS is used to
objectively describe the extent of impaired consciousness in all types of acute
medical and trauma patients. The severity of the head injury can be assessed
and prognosis can be predicted. The GCS range is classified into three
severity categories mild (GCS 13-15), moderate (9-12) and severe (3-8)
categories.

1
 The GCS and its total score have since been incorporated in numerous
clinical guidelines and scoring systems for victims of trauma or critical illness.
Reporting each of these separately component provides a clear,
communicable picture of a patient. The findings in each component of the
scale can aggregate into a total Glasgow Coma Score which gives a less
detailed description but can provide a useful summary of the overall severity
(Teasdale, Murray, Parker & Jennett ,1979). The score expression is the sum
of the scores as well as the individual elements. For example, a score of 10
might be expressed as GCS10 = E3V4M3.

Therefore, in emergency care GCS is a crucial assessment and used

as a guide for delivering a good care for patient. This is an effective
instrument to monitor trends in level of consciousness in patient especially for
paramedic who is duty in pre- hospital care, triage counter up to resuscitation
room or even in definitive care because altered level of consciousness may
present as a first sign of deterioration. This supported by Haukoos et, al
(2007) state that GCS recognizes only three levels of motor response which
may be sufficient to support binary decisions, for example for intubation, in
prehospital care and emergency room but it has no advantage over the GCS
Score in identifying early mortality.

2
1.3 Problem statement

The GCS is the most common neurological assessment tool and is widely
used to measure arousal and cognition. The GCS is important in assessment
of responsiveness to guide early management of patients with a head injury or
other kind of acute brain injury. Besides, the decisions in more severely
impaired patients include emergent management such as securing the airway
and triage to determine patient transfer. According to Winship et al. (2012) the
accurate assessment of a patient’s conscious state using the GCS is
important for paramedics as it may determine the patient’s management. The
accurate assessment of a patient’s conscious state using the GCS is a
fundamental for paramedics as it may determine the patient’s initial, and
ongoing management.

Moreover, the GCS is routinely measured by ED nurses and paramedic

which relying on the accuracy of this information to make clinical decisions, a
reliable GCS must be obtained in order to recognize patients in need of urgent
intervention and to identify patients whose clinical condition has suddenly
changed (Holdgate et al., 2006). A study was conducted in the Emergency
and Outpatient Departments of a Tertiary Medical Centre, result showed that
55.56% of nurses had poor knowledge followed by 41.48% and 2.96% with
satisfactory knowledge and good knowledge, respectively (Basauhra Singh et
al., 2016). Meanwhile, based on a study in Bharatpur, the result shows that
only 33.1% of the nurse had good level of knowledge. This shows that
healthcare worker does not have adequate knowledge regarding GCS
(Sedain & Bhusal, 2019).

Besides, another study by Thi & Chae (2011) state that whereas 52.1%
of the nurses answered incorrectly questions related to clinical scenarios
requiring the application of the basic knowledge and these findings indicate
that the Vietnamese nurses are not able to integrate their GCS knowledge
into actual practice as measured by the accuracy of GCS scoring. This
supported by a study done in Tertiary Hospital in Ghana, half of the

3
participants (50.4%) had low knowledge of the GCS as a whole and they are
not able to apply that basic knowledge in clinical scenarios (Alhassan et al.,
2019).

Based on the previous study about GCS, as a researcher strongly

believe that knowledge on GCS is very important to apply in managing the
patient and it must score accurately as it is will affect the patient’s outcome. In
Malaysia, there have been increasing cases of head injury were caused by
motor vehicles accident and other neurological condition that require the use
of GCS assessment. As an example, In 2009, the National Trauma Database
Malaysia reported that nearly 80% of traumas in the population were caused
by road traffic accidents, with 64% of these cases related to head injury. This
data supported by car accident trend & statistic for 2022, an estimated 1.3
million people die in car crashes each year or about 3,287 deaths per day. An
additional 20-50 million people are injured or disabled in car accidents each
year. Early detection of any neurological status change is highly important.
This might decrease the morbidity, mortality and improve patients' outcomes.
Contrary, failure to do so could lead to irreversible and devastating
consequences. So, paramedic should be knowledgeable and confident in
GCS assessment. Dissemination of simplified knowledge and benchmarks
among nurses and health care professionals is essential (Bsn & Aburuz,
2016)

Despite the increasing level of incidence and prevalence of

neurological and head injury caused by accident cases with few studies
establishing the knowledge of GCS by nurses. From the researcher’s
experience and observations while on clinical site in the pre- hospital care and
Emergency Department (ED) where unconscious patient evaluation, practices
of nurses in assessing patients using the GCS seem incongruent,
occasionally leading to an inaccurate assessment of the patient’s condition.
Therefore, the question that stimulated the study was how how is the
paramedic’s knowledge of GCS? Hence, in this study the researcher aim to
study about the knowledge of Gloscow Coma Scale (GCS) among student

4
Advance Diploma Emergency Care (ADEC) batch cohort 7 in ILKKM Sultan
Azlan Shah.

5
1.4 Research objective

General objective

To study about knowledge of Glasgow Coma Scale (GCS) among student

Advance Diploma Emergency Care (ADEC) batch cohort 7 in ILKKM Sultan
Azlan Shah.

Specific objective

1. To identify about the level of knowledge in Glasgow Coma Scale (GCS)

among student Advance Diploma Emergency Care (ADEC) batch cohort 7 in
ILKKM Sultan Azlan Shah.

2. To determine difference of knowledge of GCS between profession among

student Advance Diploma Emergency Care (ADEC) batch cohort 7 in ILKKM
Sultan Azlan Shah.

3. To determine association between the level of knowledge of GCS and

working experience student Advance Diploma Emergency Care (ADEC) batch
cohort 7 in ILKKM Sultan Azlan Shah.

Research question

The research questions of this study are:

1. What are the level of knowledge in Glasgow Coma Scale (GCS) among
student Advance Diploma Emergency Care (ADEC) batch cohort 7 in ILKKM
Sultan Azlan Shah.

2. Is there any difference between the profession with the knowledge of

Glasgow Coma Scale among ADEC student Cohort 7 in ILKKM Sultan Azlan
Shah?

6
3. Is there any association between working experience with the level of
knowledge on Glasgow Coma Scale in (ADEC) cohort 7 student in ILKKM
Sultan Azlan Shah?

1.5 Research hypothesis

1. Alternative Hypothesis

There is a significant difference of knowledge between type of profession

among Advance Diploma Emergency care (ADEC) student cohort 7 in ILKKM
Sultan Azlan Shah.

• Null Hypothesis
There is no significant difference of knowledge between type of profession
among Advance Diploma Emergency care (ADEC) student cohort 7 in ILKKM
Sultan Azlan Shah.

2. Alternative Hypothesis

There is a significant association between the level of knowledge in GCS and

working experience student Advance Diploma Emergency Care (ADEC) batch
cohort 7 in ILKKM Sultan Azlan Shah.

• Null Hypothesis
There is no significant association between the level of knowledge in GCS
and working experience student Advance Diploma Emergency Care (ADEC)
batch cohort 7 in ILKKM Sultan Azlan Shah.

1.6 Significance of the study

The finding of the study will determine the informational needs and the
steps to increase the knowledge of GCS among student Advance Diploma
Emergency Care (ADEC) batch Cohort 7. The informational needs from this
research will help the health care personnel to improve the knowledge in
GCS. Furthermore, GCS will be used in daily work to the patient that come to

7
hospital, using the finding of the study, health care personnel able to use it for
awareness, knowledge and preparedness in a situation. Moreover, based on
the finding of this study, we can know the knowledge between health care
personnel. This is because, the informational in GCS will utilized by health
personnel. Hopefully the finding of the study can be use as the guideline to
prepare and aware about the importance of knowledge in GCS.

1.7 Research scope

This research is A study about knowledge of Glasgow Coma Scale (GCS)

among student Advance Diploma Emergency Care (ADEC) batch cohort 7 in
ILKKM Sultan Azlan Shah. It involves the participation of whole student
Advance Diploma Emergency Care (ADEC) batch cohort 7 in ILKKM Sultan
Azlan Shah. The data will be collected using the questionnaire. At the end of
each session, the respondent was requested to keep their individual answer
confidential until the data collection phase had been fully completed.

1.8 Definition of terms

The following are the definitions of constructs investigated in this study:

Glasgow coma scale

The GCS is the summation of scores for eye, verbal, and motor responses.
The minimum score is a 3 which indicates deep coma or a brain-dead state.
The maximum is 15 which indicates a fully awake patient.

Knowledge
Facts, information, and skills acquired through experience or education; the
theoretical or practical understanding of a subject.
Awareness or familiarity gained by experience of a fact or situation.

Profession

8
A profession is an occupation founded upon specialized educational training,
the purpose of which is to supply disinterested objective counsel and service
to others, for a direct and definite compensation, wholly apart from
expectation of other business gain.

Working experience
Working experience is any experience that a person gains while working in a
specific field or occupation.

1.9 Summary

This chapter introduces the issue related to the topic under investigation
and explain the basic idea of the research. In particular, this chapter briefly
explains the study about knowledge of Glasgow Coma Scale (GCS) among
student Advance Diploma Emergency Care (ADEC) batch cohort 7 in ILKKM
Sultan Azlan Shah. Then, this chapter outlines the research objectives to
pursue, the research questions that set out the problem to be addressed, the
significance of the study, and the definition of constructs. The next chapter
offers discussion of the existing literature and research framework.

9
 CHAPTER 2
LITERATURE REVIEW

2.1 Introduction

This literature would describe the information about the importance of GCS
and the knowledge in GCS among paramedic.

2.2 Overview on Gloscow Coma Scale (GCS)

The Glasgow Coma Scale (GCS) provides a structured method for

assessment of the level of consciousness. BrainLine (2019), the GCS is the
most common scoring system used to describe the level of consciousness in
a person following a traumatic brain injury. Basically, it is used to help gauge
the severity of an acute brain injury. The test is simple, reliable, and correlates
well with outcome following severe brain injury. The GCS is a reliable and
objective way of recording the initial and subsequent level of consciousness in
a person after a brain injury. It is used by trained staff at the site of an injury
like a car crash or sports injury, for example, and in the emergency
department and intensive care units.

2.3 Relevant literature to the knowledge of paramedic in gcs

According to study at the Hospital of Bharatpur, Chitwan: Knowledge

Regarding Glasgow Coma Scale among Nurses Working at Selected
Hospitals of Chitwan by Sedain & Bhusal (2019), a descriptive cross-sectional
study was conducted among 154 nurses working in the different critical wards
(like ICU, CCU, NICU) of Bharatpur using convenient sampling. Finding on
this study shows that only 33.1% of the nurse had good level of knowledge.
Likewise, 66.9% nurses had good knowledge regarding eye-opening
component, 33.0% had good knowledge regarding motor component and
66.2% had good knowledge regarding verbal response of GCS. It is
concluded that majority of nurses have unsatisfactory level of knowledge

10
regarding GCS. This shows that there should be more structured and detailed
approach that should be implement to improve the nurse’s knowledge.

A study conducted by Winship et al. (2013) concluded that the

undergraduate paramedic students from Australian university were unable to
assess GCS accurately if the patient’s GCS score was lower than 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 misjudgement of the
reaction response. Another study conducted by Alhassan et al., (2019) a
descriptive cross-sectional study involving a convenience sample of 115
nurses from a large teaching hospital in Ghana using a structured
questionnaire. A little more than half of the participants (50.4%) had low
knowledge of the GCS as a whole. However, with respect to basic theoretical
concepts of the GCS, 62.6% of the participants had good knowledge about it,
while only 5.2% demonstrated good knowledge on application of the basic
knowledge in clinical scenarios. The findings from this study showed that
nurses in Ghana have low levels of knowledge about the GCS. A more
structured approach to teaching the GCS that is very thorough and done with
demonstrations should be implemented to improve nurses’ knowledge on the
GCS.

Moreover, to support the study about the knowledge in GCS of nurses

can be seen in a study Perspectives in Nursing Science at general hospital in
Ho Chi Minh City, Vietnam: The Accuracy of Glasgow Coma Scale
Knowledge and Performance among Vietnamese Nurses by Thi & Chae
(2011). A cross-sectional descriptive study was conducted using a
questionnaire pertaining to the nurses’ knowledge of GCS and a structured
evaluation tool to measure the accuracy of their GCS scores. A total of 94
Vietnamese nurses participated in this study. This study found that the vast
majority of the nurses (>90%) responded correctly to questions regarding their
GCS basic knowledge; however, 52.1% of the nurses answered incorrectly
11
questions related to clinical scenarios requiring the application of the basic
knowledge. Regarding the GCS performance, the nurses demonstrated
acceptable accuracy rates for each component of GCS, but those who scored
well in all three components accounted for only 42.6% of the subject group.
These findings indicate that the Vietnamese nurses are not able to integrate
their GCS knowledge into actual practice as measured by the accuracy of
GCS scoring. This shows that new educational strategies should be
developed for the nurses to improve their performance on accurate GCS
scoring based on theoretical knowledge.

Besides, based on a study was conducted in the Emergency and

Outpatient Departments of a Tertiary Medical Centre: Assessing Nurses
Knowledge of Glasgow Coma Scale in Emergency and Outpatient
Department by Basauhra Singh et al, (2016). This study is a quantitative
descriptive cross-sectional study design using the GCS Knowledge
Questionnaire. Convenience sampling method was used on 135 personnel
participated in this study. Result showed that 55.56% of nurses had poor
knowledge followed by 41.48% and 2.96% with satisfactory knowledge and
good knowledge, respectively. This finding raises concerns on the importance
of knowledge and skill in assessing GCS. Continuing education and practice
on use of the GCS tool are important.

This supported by a study that was conducted at Pediatric intensive

care unit in Pediatric hospital at Zagazig University Hospital’s Pediatric,
intensive care unit at Al Ahrar Hospital and Pediatric intensive care unit at
General Hospital: Nurses Knowledge and Practice Regarding Care of
Comatose Children at Pediatric Intensive Care Units by Mohamed & El-
dakhakhny (2019), descriptive design was used which included all accessible
nurses who work at the previous setting. The study results revealed that the
total scores of nurses' knowledge was good, fair and poor with percentage
69.2, % 27.7% and 3.1% respectively while the total practices level of all
studied nurses were unsatisfactory.

12
 However, study was carried out in the Dhafra hospitals, Abu Dhabi,
United Arab Emirates: Assessment of Nurse’s Knowledge About Glasgow
Coma Scale at al Dhafra Hospitals, Abu Dhabi, United Arab Emirates 2018 by
Ayoub et al (2018).It is a cross-sectional, descriptive study with 165 nurses as
respondent. On the other hand, it revealed also that the percentages of
nurses who have a good knowledge about GCS were 50.6% and staffs whom
have poor knowledge were 49.4 %. 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.

This finding raises concerns about the importance of knowledge and

skill in assessing GCS. Even though, some of the literature state the
information about knowledge of the healthcare worker showing is poor, but
there is still some study show that the knowledge of healthcare worker is
good. However, all the literature was conducted in different range of time and
different place, so the result of knowledge in GCS is clearly different from
each other.

2.4 Conceptual Framework

Profession

Knowledge Of
13 Gloscow Coma
Scale (GCS)
 Working
Experience

2.5 Summary

There is a lot of study that showed the knowledge in paramedic are still
inadequate. The result of each study was different and some of them are
related each other. Thus, it may be hard for us to determine which factors
affecting the knowledge in GCS of healthcare medical personnel but we take
this as challenge for us to conducting research. The next chapter offers
discussion of methodology of this study consists of a research design,
research setting, population and sampling, instrument, variables, data
collection procedure, flow chart of data collection, proposed plan for data
analysis and ethical consideration.

14
 CHAPTER 3
METHODOLOGY

3.1 Introduction

The system of collecting data for research project which is known as research
methodology will be discuss in this chapter. The methodology of this study
consists of a research design, research setting, population and sampling,
instrument, variables, data collection procedure, flow chart of data collection,
pilot study, proposed plan for data analysis and ethical consideration.

3.2 Research design

This study was a descriptive quantitative, cross-sectional study which is

targeted all advance diploma in emergency care cohort 7 of Institute Latihan
Kementerian Kesihatan Malaysia Sultan Azlan Shah. In this study, variables
are described and the relationship between variable will be examined. This
study focusing to seek for association of their knowledge and their
demographic data. Due to the limitation of the time and resources, a cross
sectional study has been chosen because it is the most convenient type of
study based on my limitations.

3.3 Research setting

This study will be carried out on the students of Advanced Diploma in

Emergency Care cohort 7 which is study in Institute Latihan Kementerian
Kesihatan Malaysia Sultan Azlan shah

3.4 Duration for data collection

Duration for data collection in this study between 9hb April 2022 untill 11 April
2022 (during mid semester break)

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3.5 Population and sampling

3.5.1 Population
The study population for this study will consist of selected Advanced Diploma
in Emergency Care 1/2020 cohort 7 student in Institute Latihan Kementerian
Kesihatan Malaysia Sultan Azlan Shah.

3.5.2 Sample size

This study will use the sample size by using Krejcie & Morgan’s Table (1970)
which is using 40 population and sample size of 36 with 10% drop out.

3.5.3 Sampling
The simple random sampling has been chosen to conduct this research
project.

3.5.4 Inclusion criteria.

The researcher selected cases among:
• Advance Diploma in Emergency Care Cohort 7.
• Students of ILKKM Sultan Azlan Shah

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• Works as paramedic.

3.6 Research instrumentation

For this study, a questionnaire that developed by Mattar et al., (2013) and
Sedain & Bhusal (2019), was utilized to collect the data of study. This
instrument consists of 2 sections.

Section A: Consists of 3 questions regarding socio demographic data such

as profession, gender and working experience.

Section B: Consist of 20 questions regarding the respondent knowledge

about the GCS. The multiple choices questions will be distributed to the
respondent regarding the knowledge in GCS.

The scoring in level of knowledge in GCS will be using the table below that
consist of four categorical which are excellent, good, average and poor
knowledge.

Level Of Knowledge Chart

Level of knowledge Score (%)

Excellent 75-100

Good 60-74

Average 45-59

Poor 0-44
Sources: Unit Pembangunan Kurikulum, Bahagian Pengurusan Latihan
Kementerian Kesihatan Malaysia, 2011

3.6.1 Variables

Dependent variable
1. The knowledge of GCS

17
Independent variable
1. Profession which are Assistant Medical Officer and Registered Nurse.
2. Working experience

VARIABLE VARIABLE MEASUREMENT

• Knowledge • Numerical
• The level of knowledge • Categorical
• Working Experience • Categorical
• Profession • Categorical

3.7 Pilot study

Saunders et al., (2007) state that prior to using the questionnaire to collect
data it should be pilot tested. Saunders et al., (2007) point out the purpose of
the pilot test is to refine the questionnaire so that the respondents will have no
problems in answering the questions and also there will be no problems in
recording the data.

A combination of questionnaire by previous studies done on similar topics

has been used for this study. The questionnaires used are from Mattar et al
(2013) and Sedain & Bhusal (2019). It has two parts: demographic data sheet
(DDS) and knowledge in GCS. A general accepted rule that α of 0.6-0.7
indicates an acceptable level of reliability, and 0.8 or greater a very good
level. However, value higher than 0.95 are not necessarily good, since they
might be an indication of redandance (Hulin, Netemeyer, and Cudeck, 2001).
Validity of the subscale items used in the study will be test by caring out pilot
study. The criteria of respondent are from ILKKM Kuala Terengganu’s student
with same background which is Advance Diploma in Emergency Care Cohort

18
7, students of Institut Latihan Kementerian Kesihatan Malaysia and works as
a paramedic. The validity value is 0.76.

3.8 Data collection procedure

After obtain an approval from the Ethics Committee and also a permission
from the director of Institut Latihan Kementerian Kesihatan Malaysia Sultan
Azlan Shah, research project will start for data collection. The researchers will
survey the number of populations that will involve in the research project. To
pick the respondents, all of inclusion and exclusion criteria will be considered.
The random respondents will be pick among the population of Advance
Diploma in Emergency Care cohort 7. If they agree to participate, the consent
will be signs and questionnaire will be answer by them. If they are not
agreeing to participate, the researchers will find the other possible
respondents.

3.8.1 Flowchart for data collection

Obtain the approval from College Director

Obtain the number of ADEC cohort 7 student

Consider Inclusion Criteria and Exclusion Criteria

Aproach the students, and explain about the research study

Students agree to participate Students refuse to participate

Obtain consent Find other possible students

Questionaire given to students

Analyze data 19
3.1 Proposed plan for data analysis

All data must be kept as private and confidential. The data will be collected
and processed using a statistic software which is SPSS version 22.

No Objective Statistical Test

1 To identify about the level of knowledge in Descriptive
Glasgow Coma Scale (GCS)
To determine differences between profession
2 with the knowledge in Glasgow Coma Scale Mann- Whitney U
among ADEC student Cohort 7 in ILKKM Sultan
Azlan Shah.
Association between working experience with the
3 level of knowledge of Glasgow Coma Scale in Pearson chi square
(ADEC) cohort 7 student in ILKKM Sultan Azlan (Fisher Exact Test)
Shah.

3.2 Ethical Considerations

Researcher will apply the ethic approval for this study from the Institut
Latihan Kementerian Kesihatan Malaysia Sultan Azlan Shah Research Ethics
Committee before starts research project. Researcher seek for permission
from the director of Institut Latihan Kementerian Kesihatan Malaysia Sultan
Azlan Shah to run the research project at his premise.

3.3 Summary

The methodology is very important in a study that will be conducted.

According to US Libraries (2020), readers need to know how the data was
obtained because the method you chose affects the results and, by extension,

20
how you interpreted their significance in the discussion section of your paper.
As for this study, quantitative research that apply descriptive, cross-sectional
study will be applied to obtain the data. Besides, the simple random sampling
has been chosen to conduct this research project where 36 with 10% drop out
respondent will be chosen and the tools will be used is questionnaire that
consist of two part which are demographic data and 20 question about
knowledge in GCS.

21
 CHAPTER 4
DATA ANALYSIS

4.1 Subject demographic

A total of 40 participant met the inclusive criteria, 38 participants

agreed to be recruited for this study. 2 participants not complete answering
the questionnaire. Therefore, the total for participants for this study is 36
persons only. Of these, the ratio of female to male participant were 2: 1 which
is 22 participants is female and 14 participant is male. Out of 23 participant is
registered nurses, meanwhile 13 participant is assistant medical officer.
55.6% of participant (20 person) had more than 7 years working of
experience, while 44.4% of participant (16 person) had less than 7 years of
working experience. Demography data of the study participants are shown in
Table 1.

Table 1 Social Demography data of the studied participant (n= 36)

Variables Frequency (n) Percentage %

Gender
Male 14 (38.9)
Female 22 (61.1)

Profession
Assistant Medical 13 (36.1)
Officers 23 (63.8)
Registered Nurse
Working Experience
0-7 years 16 (44.4)
>7 years 20 (55.6)

22
4.2 Level of knowledge in Glasgow Coma Scale

63.9% (23 participant) from the study population were having excellent
level of knowledge in Glasgow Coma Scale. Followed by 25% (9 participant)
having good level of knowledge in Glasgow Coma Scale and 11.1% (4
participant) having average level of knowledge. The level of knowledge in
Glasgow Coma Scale among student Advance Diploma Emergency Care
(ADEC) batch 7 in ILKKM Sultan Azlan Shah are shown in Table 2.

Table 2 The level of knowledge in Glasgow Coma Scale among student

Advance Diploma Emergency

Care (ADEC) batch 7 in ILKKM Sultan Azlan Shah

Level knowledge in Glasgow Coma Frequency Percentage

Scale
Excellent 23 63.9%
Good 9 25%
Average 4 11.1%

4.3 The differences of participant’s knowledge in Glasgow Coma Scale

and profession.

A Mann-Whitney U test was conducted to evaluate the hypothesis that

there is no significant difference of knowledge between assistant medical
officer and nurses among Advance Diploma Emergency care (ADEC) student
cohort 7 in ILKKM Sultan Azlan Shah. The results of the test were not in the
expected direction and not significant, z = -.956, p > .05. The test indicated
that the difference was not statistically significant. Hypothesis null was
accepted. Based on Table 3 and Table 4, the result shown U (N Assistant
Medical Officer = 13, N Registered nurse = 23) = 121.00, z = -.956, p= .339.

23
Assistant Medical Officer had an average rank of 16.31, while nurses had an
average rank of 19.74. Therefore, there is no significant difference of
knowledge between assistant medical officer and nurses among Advance
Diploma Emergency care (ADEC) student cohort 7 in ILKKM Sultan Azlan
Shah.

Table 3 The differences of participant's knowledge on Glasgow Coma Scale

and profession
Sum of
Profession N Mean Rank Ranks
Knowledge of Assistant Medical 13 16.31 212.00
GCS Officer
Registered Nurse 23 19.74 454.00
Total 36

Table 4 Result of the Mann-Whitney U analyses between participant's

knowledge on Glasgow Coma Scale and profession

TOTAL
Mann-Whitney U 121.000
Wilcoxon W 212.000
Z -.956
Asymp. Sig. (2-tailed) .339
Exact Sig. [2*(1-tailed .361b
Sig.)]
a. Grouping Variable: 1.
Profession
b. Not corrected for ties.

24
4.4 The association between the level of knowledge in Glasgow Coma
Scale and working experience.

50 % cell have expected count less than 5. We used the Fisher's exact
test will be applied. Fisher's exact test value is 2.760, p= .283 p>.05. So, we
accept null hypothesis Therefore, there is no significant association between
working experience and level of knowledge. The result shown in Table 5.

Chi Square Analysis (Fisher’s Exact Test)

The level of knowledge in GCS

Excellent Good Average Frequency (n)
Working 0-7 years 8 5 3 16
Experience >7 years 15 4 1 20
Total 23 9 4 36

fisher's exact test value is 2.760, p= .283 p>.05

25
 CHAPTER 5
DISCUSSION

Glasgow Coma Scale (GCS) is a tool used by paramedic in almost

every healthcare facility to assess level of consciousness in a patient with a
neurological problem. It is important to have the skill and knowledge when
assessing and applying critical thinking to interpret the findings. This study
showed that 63.9%of the respondent had excellent knowledge, 25% had good
knowledge and 11.1% had average knowledge of the GCS. This study’s
finding is similar to research done by Teles et al (2013), who found that
74.55% of the nurses had average knowledge and 25.45% had poor
knowledge in GCS. Moreover, this finding is in tandem with the finding of Thi
& Chae (2011), who studied the knowledge and performance of the GCS
among Vietnamese nurses and reported that >90% of the participant
answered correctly to questions about basic knowledge of the GCS, but
52.1% answered wrongly questions that required application of the basic
knowledge in a clinical scenario. However, the finding differs from a study
done by Jaddoua et al., (2013), that showed all nurses (n=100) had
inadequate knowledge in GCS. According to AL-Quraan & AbuRuz (2015), all
of the students were posted to the government hospital which record higher
occupancy rate more than private hospital which allow the student to perform
GCS more frequently. In addition, they are posted to a teaching hospital
where student do their training with their local preceptor and grand round are
done daily with multidisciplinary team in the general hospital. Taking all these
into consideration, it can conclude that is why student ADEC Cohort 7 are
knowledgeable.

Moreover, profession is not the factor in the knowledge of GCS as

shown in this study. The result shows that there was no differences where p
value is 0.339, p > .05. The test indicated that the difference was not
statistically significant. U (N Assistant Medical Officer = 13, N Registed nurse

26
= 23) = 121.00, z = -.956, p= .339. Null Hypothesis was accepted. Therefore,
there is no a significant difference between the knowledge of GCS among
Assistant Medical Officer and registered Nurses. To the best of researcher
knowledge, this is the first study to evaluate difference between profession
among assistant medical officer and registered nurse. There are no previous
studies found using several search engines regarding level of knowledge and
profession in Malaysia and other different country. In other country, there is no
assistant medical officer profession. However, assistant medical officer is one
of the members in the Global Association of Clinical Officer and Physician
Associate, a world organization that bringing together all that clinical officer,
physician assistant, physician associate, sub health extension officer and
many other names that came from different countries. Although the
professions come with different name, the scope of work is almost similar.
According to a study done by Bryan E. Bledsoe., (2015), between EMTs,
advance EMTs, paramedics, critical care paramedic, ED nurse, ED physicians
and emergency medicine residents, the finding shows that resident were the
most accurate at 51% with nurse being the least accurate at 29%. There is
another study done by Báez et al., (2007), where there was no significance
difference observed between 17 physician and 45 (nurses and paramedic).
The study finding shows that there is no a significant mean difference
between the knowledge of GCS among Assistant Medical Officer and
registered Nurses. In researcher point of view, assistant medical officer and
registered nurse undergo a similar year of training at the same learning
institute under ILKKM. They are required to fulfill the same duration of posting
hours. Besides, they also learn the same basic curriculum in their training
years. Therefore, all of these points might be the reason that contribute their
knowledge in GCS.

Besides, the results of this survey show that who are working
experience less than 7 years are 16 respondents (44.4%) and 20 respondents
(55.6%) are more than 7 years. 8 respondent who work less than 7 years had
excellent knowledge of GCS compared to 15 respondent who work more than
7 years had excellent knowledge regarding GCS. However, the result’s finding
shows that fisher's exact test value is 2.760, p= .283 p>.05. Null hypothesis
27
was accepted. Therefore, there is no significant association between working
experience and the level of knowledge in GCS. This result is similar to a study
done by Ehwarieme & Anarado (2016), where there was no significant
association between the nurse’s gender, age, level of education and years or
working experience and their level of knowledge (p>0.05). Another study done
by Jaddoua et all., (2013), it also stated that there was no significant
relationship between years of work in hospital and nurse’s knowledge (C. C =
0.188). However, in contrast based on as study by Mattar et al., (2013),
nurses who worked in a neuroscience setting for 6 years or more scored
higher mean scores (11.9) on the knowledge scale, whereas nurses who
worked in a neuroscience setting less than a year scored lower mean scores
(10.0). This study shows that there is no huge difference between working
experience based on their mean score. From this study, researcher able to
find out that working experience does not affect the knowledge in GCS among
ADEC Cohort 7 student. According to Bsn & Aburuz (2016), participant was
considered experienced if he/she had a minimum of two years of nursing
experience and at least one year of current neuroscience nursing practice.
Hence, all of the participant are considered experienced as all of them are
working more than two years in practice.

28
 CHAPTER 6

LIMITATION, RECOMMENDATION AND CONCLUSION

6.1 INTRODUCTION

This chapter discussed the limitation, recommendation and conclusion

of the study.

6.2 LIMITATION

In completing this research, there were several limitations that

researchers found. Firstly, the main limitation that we faced was there is
inadequate data and research that has been performed regarding knowledge
of Glasgow Coma before especially in our country, Malaysia. There are only a
few studies regarding Glasgow Coma Scale that has been done before that
cause hard for researcher to get an information and a guide to complete the
study. However, researcher managed to get some journal and information that
quite similar regarding this study but it is mainly done at other country. This
makes the researchers more interested to conduct this study since this study
based at researcher own country and may be useful as information for future
researcher that interested to study about Glasgow Coma Scale in Malaysia.

Subsequently, the population that involve in this study is limited

and in small population. Hence, the result that found from this study cannot
reflect the overall knowledge about Glasgow Coma Scale among another
Cohort. However, the researcher hope that will a chance in future to do further
studies about the Glasgow Coma Scale and expand the population that will
involve hoping for better result. With a better result, it will show a real
condition of knowledge of paramedics nowadays and based on that, it will
help in getting some recommendation step in improving the paramedics
knowledge towards Glasgow Coma Scale.

29
 Lastly, the time and cost also become limitation in conducting
this study. The researchers need to arrange their time wisely since the
duration for this study need to be submitted less than 1 year. Moreover,
packed schedule of class and also an attachment at the hospital need the
researcher to divide properly their time. For cost aspect, the researchers did
not receive any aid in process to complete this study. This needs for
researchers spend their own fund for completing this research.

6.3 RECOMMENDATION

From the result of this study, the researcher would like to suggest
some recommendation step in order to improve our paramedics knowledge
towards Glasgow Coma Scale.

Firstly, the continuous education session such as a continuous medical

education (CME) session about Glasgow Coma Scale should be perform
regularly for all of paramedics. By holding this education session, it will
improve the paramedic knowledge about Glasgow Coma Scale and ensure
that the paramedics will gaining up to date information and refreshing all of
the knowledge that has been learnt before.

Secondly, the courses regarding GCS should be done regularly.

Courses that included GCS as tools to proceed management are Advanced
Life Support (ALS) and Advanced Trauma Life Support (TLS). In these
courses, paramedic able to learn and practice to apply Glasgow Coma Scale
to the scenario given as it is an important tool used to ensure proper
management can be done.

Thirdly, Basic and post basic educational programmed for student to

ensure that GCS knowledge is in depth and demonstrated in classroom,
simulation laboratories and during clinical experience. It is important to have

30
the knowledge when assessing and applying critical thinking to interpret the
findings.

31
6.4 CONCLUSION

As a conclusion, researcher have gained a positive result from this

study where the majority of participants showing a good knowledge in
Glasgow Coma Scale. In knowledge aspect, 75.5% of participants (n=44)
showed that an excellent result from this study.

In a nutshell, researcher believe the generalization of the finding from

this study might not be accurate due to the small number of participants,
however the finding still can be used as a guide in the knowledge of Glasgow
Coma Scale among student ADEC. Researcher hope that all of the finding
from this study can be use in the development of Glasgow Coma Scale our
beloved country. The researcher believed that it is important to have
continuous learning process for paramedics regarding Glasgow Coma Scale
to ensure that they always able to use correctly it in daily working setting.

32
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for Nurses. International Journal of Advanced Nursing Studies, 4(2), 69.
https://doi.org/10.14419/ijans.v4i2.4639
Alhassan, A., Fuseini, A., & Musah, A. (2019). Knowledge of the Glasgow
Coma Scale among Nurses in a Tertiary Hospital in Ghana. 2019.
Ayoub, A. Y., Saifan, A., Alaween, M., Almansouri, E. S., Hussain, H. Y., &
Salim, N. A. (2018). Assessment of Nurse’s Knowledge About Glasgow
Coma Scale at al Dhafra Hospitals, Abu Dhabi, United Arab Emirates
2018. Journal of Clinical Review & Case Reports, 3(7), 3–7.
https://doi.org/10.33140/jcrc/03/07/00002
Báez, A. A., Giráldez, E. M., & De Peña, J. M. (2007). Precision and reliability
of the glasgow coma scale score among a cohort of latin American
prehospital emergency care providers. Prehospital and Disaster
Medicine, 22(3), 230–232. https://doi.org/10.1017/S1049023X00004726
Basauhra Singh, H. K. a/p, Chong, M. C., Thambinayagam, H. C. a/l, Zakaria,
M. I. bin, Cheng, S. T., Tang, L. Y., & Azahar, N. H. (2016). Assessing
Nurses Knowledge of Glasgow Coma Scale in Emergency and Outpatient
Department. Nursing Research and Practice, 2016, 1–5.
https://doi.org/10.1155/2016/805635
BrainLine (2019). What Is the Glasgow Coma Scale? Retrieved on November
19, 2020 from URL https://www.brainline.org/article/what-glasgow-coma-
scale
Bryan E. Bledsoe, DO;1, 2 Michael J. Casey, MD;1 Jay Feldman, MD;1 Larry
Johnson, NRP;1, 2 Scott Diel, NRP;2 Wes Forred, RN;1 Codee Gorman,
B., & 1. (2015). Glasgow Coma Scale Scoring is Often Inaccurate.
Prehospital and Disaster Medicine, 30(1), 46–53.
https://doi.org/10.1017/s1049023x14001289
Bsn, H. A., & Aburuz, M. E. (2016). Simplifying Glasgow Coma Scale Use for
Nurses.

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Catangui, E. (2019). Improving Glasgow Coma Scale ( GCS ) Competency of
Nurses in One Acute Stroke Unit - A Nursing Initiative Project. 3(1), 109–
115. https://doi.org/10.36959/545/370
Ehwarieme, T. A., & Anarado, A. N. (2016). Nurses’ knowledge of glasgow
coma scale in neurological assessment of patients in a selected tertiary
hospital in edo state, Nigeria. Africa Journal of Nursing and Midwifery,
18(2), 74–86. https://doi.org/10.25159/2520-5293/1068
Faruq, M. O. (2014). Looking for an ideal coma scale: It is time to replace
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Holdgate, A., Ching, N., Angonese, L., Medicine, E., Hospital, L., Hospital, S.
G., & Wales, S. (2006). Variability in agreement between physicians and
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knowledge in using the Glasgow coma scale in an acute care hospital.
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Pearson Education India

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Sedain, P., & Bhusal, M. K. (2019). Knowledge Regarding Glasgow Coma
Scale among Nurses Working at Selected Hospitals of Chitwan , Nepal.
0657(4), 276–281. https://doi.org/10.3126/jcmsn.v15i4.24529
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(2014). The Glasgow Coma Scale at 40 years : standing the test of time.
13(August), 844–854. https://doi.org/10.1016/S1474-4422(14)70120-6
Teles, M., Bhupali, P., & Madhale, M. (2013). Effectiveness of self
instructional module on knowledge and skills regarding use of Glasgow
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working in critical care units of KLE Dr. Prabhakar Kore hospital and
medical research centre, Belgaum. Journal of Krishna Institute of Medical
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Performance among Vietnamese Nurses. 54–61.
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20 ps://libguides.usc.edu/writingguide/methodology
Winship, C., Williams, B., & Boyle, M. J. (2012). Should an alternative to the
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Woodward, S. (2016). The Glasgow Coma Scale in adults : Doing it right The
Glasgow Coma Scale in adults : doing it right. December.
https://doi.org/10.7748/en.2016.e1638

35
APPENDIX

Bubble Chart Medical

Assistant

Profession

Staffnurse

knowledge of Glasgow
Coma Scale (GCS) <5 years
among student Advance
Diploma Emergency Care
Working experience

>5 years
Lack of knowledge in GCS

training
interpretation GCS
Self problems No training/
cme or beside
teaching
Not aware the
about this
Not
important of
while working
interested
GCS
interpretation No audit or privileging
by the management to
assess the knowledge

36
 INSTITUT LATIHAN KEMENTERIAN KESIHATAN MALAYSIA [ SULTAN AZLAN SHAH ] ULU KINTA

CARTA GANTT – JADUAL PERLAKSANAAN PENYELIDIKAN DIPLOMA LANJUTAN PENJAGAAN

KECEMASAN

TUGASAN
FASA TEORI AMALI AMALI AMALI AMALI TEORI
BULAN OGOS SEPTEMBER OKTOBER APRIL/MEI JUN JULAI
2020 2020 2020 2022 2022 2022
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
MINGGU

Pemilihan tajuk &

permasalah kajian
Membina proposal &
kelulusan proposal
Kajian semula

Metodologi

Membina tools kajian

Pre test tools

Menulis laporan
lengkap bab 1 &
kelulusan penyelia
Menulis laporan
lengkap bab 2 &
kelulusan penyelia
Menulis laporan
lengkap bab 3 &
kelulusan penyelia
Kelulusan Tools
penyelia
Mengumpul data
kajian
Menganalisis data
Menulis laporan bab
4&5
Penyediaan slide
pembentangan
Penghataran buku
penulisan proposal
kepada penyelia.

37
 QUESTIONAIRE

The Knowledge of Glasgow Coma Scale (GCS) among student Advance

Diploma Emergency Care (ADEC) batch cohort 7 in ILKKM Sultan Azlan
Shah.
INSTRUCTION:

1. Kindly answer all the questions willingly with ease and calm.
2. All answers and information are confidential and only be used in this study
only
DECLARATIONS

Investigator:
1) NORSULIANA BINTI MOHD RAZALI
2) FARAH ATHIRAH BINTI MOH FUZI
3) NURUL HANANI BINTI ABDULLAH

We are student from Advanced Diploma In Emergency Care program in

ILKKM Sultan Azlan Shah. This aim of this study is to investigate The
Knowledge of Glasgow Coma Scale (GCS) among student Advance Diploma
Emergency Care (ADEC) batch cohort 7 in ILKKM Sultan Azlan Shah. The
data collected from this study will be used for academic and training purposes
only. No personal data collected will be exposed or shared to the public or be
used for commercial purposes. The participants are required to answer all the
questions in this questionnaire. If you are agreeing to participate in this study,
please answer all question. Thank you.

SECTION A: DEMOGRAPHY
Instruction: Choose one answer from the options below
1. Profession

o Assistant Medical Officer

38
o Registered Nurse

39
 2. Gender

o Male
o Female

3. Working Experience *
Please state your years of working experience (eg: 5 years)

……………………………………………………………………….
SECTION B: KNOWLEDGE OF GCS

1. What are the specific sections that comprise the Glasgow Coma
Scale?
A. Eye opening, verbal response, pupil response
B. Eye opening, verbal response, limb movement
C. Eye opening, verbal response, motor response
D. Eye opening, respiratory pattern, motor response

2. Vital signs are a component of the Glasgow Coma Scale.

A. True
B. False

3. The Glasgow Coma Scale cannot assess intubated patient’s level of

consciousness.
A. True
B. False

4. The lowest score of the Glasgow Coma Scale is?

A. 1
B. 3
C. 4
D. 10

40
5. The total maximum score of Glasgow Coma Scale is?
A. 3 / 3
B. 20 /20
C. 10 / 10
D. 15 / 15

6. Patients with a Glasgow Coma Scale score of and below are

considered comatose?
A. 1
B. 3
C. 8
D. 10

7. In nursing practice, a reduction of the Glasgow Coma Scale score of is

seen as a deterioration in conscious level and requires informing the
medical team.
A. True
B. False

8. GCS score for the eye opening if patient opens eye only on pain
stimuli?
A. 3
B. 4
C. 2
D. 1

9. GCS score for eye opening if patient opens eye only on verbal
command?
A. 3
B. 1
C. 2
41
D. 4

10. When asking a patient at hospital, “Do you know where you are now?”
the patient states he is at his daughter’s condominium. He is..
A. Orientated
B. Confused
C. Producing inappropriate words.
D. Producing incomprehensive sound

11. Interpretation of incomprehensible sounds in verbal response of GCS

score is..
A. 1
B. 2
C. 3
D. 4

12. When testing the best motor response, you…

A. Record the response in the best arm.
B. Record the response in the worst arm.
C. Record the best response from the legs.
D. Record the response in all four limbs

13. To test motor response in a tetraplegia patient (paralyzed in all four

limbs)?
A. Inflict a pain stimulus in the arms until there is a response.
B. Inflict a pain stimulus in the legs until there is a response
C. Ask the patient to nod or turn his head.
D. Lift the arm up and let it drop to the bed three times.

42
14. On assessing a patient’s motor response, he is unable to comply. You
inflict a pain stimulus on his chest and he push your hand. He…
A. Is obeying commands
B. Is localizing pain
C. Has abnormal flexion
D. Has abnormal extension

15. GCS score for motor response if the patient localizes to the painful
stimuli?
A. 2
B. 3
C. 4
D. 5

16. GCS score for motor response if the patient obeys verbal command?
A. 2
B. 4
C. 5
D. 6

17. GCS score if patient opens eyes only after verbal command, uses
inappropriate word and localizes the area of pain stimuli?
A. E3V3M5
B. E2V3M6
C. E4V4M5
D. E3V2M5

18. 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?
A. 11
43
B. 12
C. 13
D. 14

..
19. When you provided pain stimulus, your patient extends and abducts
both arms away from body. This response characterizes ?

A. Withdrawal to pain
B. Decerebrate posturing
C. Localized pain
D. Decorticate posturing

20. 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 ?

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

44
45
STATISTIC DATA

Data - Negatively skewed distribution

Tests of Normality
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
TOTAL .168 36 .012 .882 36 .001
a. Lilliefors Significance Correction

P< .05, data significant, therefore data is not normal distributive

46
OBJECTIVE 1

Level of knowledge

Cumulative
Frequency Percent Valid Percent Percent
Valid excellent 23 63.9 63.9 63.9
good 9 25.0 25.0 88.9
average 4 11.1 11.1 100.0
Total 36 100.0 100.0

OBJECTIVE 2

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Ranks
Sum of
Profession N Mean Rank Ranks
TOTAL Assistant Medical
13 16.31 212.00
Officer
Registed Nurse 23 19.74 454.00
Total 36

Test Statisticsa
TOTAL
Mann-Whitney U 121.000
Wilcoxon W 212.000
Z -.956
Asymp. Sig. (2-tailed) .339
Exact Sig. [2*(1-tailed
.361b
Sig.)]
a. Grouping Variable: 1.
Profession
b. Not corrected for ties.

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OBJECTIVE 3

LEVEL OF KNOWLEDGE * Working Experience Crosstabulation

Working Experience
0-7 >7 Total
LEVEL OFExcellent Count 8 15 23
KNOWLEDG Expected Count 10.2 12.8 23.0
E
Good Count 5 4 9
Expected Count 4.0 5.0 9.0

Average Count 3 1 4
Expected Count 1.8 2.2 4.0

Total Count 16 20 36
Expected Count 16.0 20.0 36.0

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Chi-Square Tests
Asymp.
Sig. (2-Exact Sig.Exact Sig.Point
Value df sided) (2-sided) (1-sided) Probability
Pearson Chi-
2.832a 2 .243 .249
Square
Likelihood Ratio 2.877 2 .237 .249
Fisher's Exact Test 2.760 .283
Linear-by-Linear
2.752b 1 .097 .147 .079 .051
Association
N of Valid Cases 36
a. 3 cells (50.0%) have expected count less than 5. The minimum expected count is
1.78.
b. The standardized statistic is -1.659.

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