Improving Pediatric Critical Care Nurses’ Practice in Implementing the Full Outline of Unresponsiveness Coma Scale

Abstract

Introduction

Clinical estimation of consciousness is the most fundamental and crucial component of neurological examinations for pediatric patients in the pediatric intensive care unit (PICU). The full outline of unresponsiveness (FOUR) Coma Scale assesses four variables: eye response, motor response, brainstem reflexes, and respiratory pattern. A score of 0 represents non-function in each category, whereas a score of 4 indicates normal functioning. The FOUR Coma Scale is easy to apply and is currently the most widely used scale for assessing consciousness, particularly in intubated children.

Objectives

This study aimed to improve pediatric critical care nurses’ practice in implementing the FOUR Coma Scale.

Methods

A quasi-experimental research design (pre/post-test design) was employed on a convenience sample composed of 45 male and female nurses who participated in the study and provided direct care for critically ill children at the Medical Pediatric Intensive Care Unit affiliated with the Mansoura University Children's Hospital, Mansoura University, Egypt. All the participants completed the FOUR Coma Scale knowledge and practice assessment questionnaire.

Results

Majority of the nurses were females and had bachelors’ degrees in nursing (94.6% and 71.1%, respectively). Moray Coma Scale was used to assess level of consciousness (LOC) by more than half the number of nurses (55.6%) in the PICU. All PICU nurses had poor knowledge and practice scores in the pre-intervention phase, and this percentage statistically significantly improved in the post-intervention phase (P = .001).

Conclusion

The mean score of nurses’ knowledge and practice on the FOUR Coma Scale significantly improved after the implementation of instructional intervention.

Introduction

Evaluating the level of consciousness (LOC) of critically ill children is a significant aspect of care in pediatric intensive care units (PICUs). The LOC is the degree of a child's ability to interact with other people, ability to be awake, aware, and react to the surroundings. A decreased LOC is a serious health concern. Extreme irritability for more than 3 hours is one of the symptoms of decreased LOC in young children. Assessing altered consciousness in children poses a significant challenge and holds great importance in emergency care settings. Unlike vital signs, there is no standardized objective measure to effectively communicate and document the severity of coma. Consequently, clinicians and nurses often resort to utilizing clinical scores or scales to accurately record and communicate the LOC (Jamal et al., 2017).

Critically ill children commonly exhibit varying degrees of altered consciousness and coma, in particular, presents a neurological emergency associated with significant morbidity and mortality. The etiology of non-traumatic coma is diverse, and timely recognition and treatment of the underlying causes are crucial to prevent long-lasting effects, including permanent neurological deficits. After addressing any immediate concerns identified through the ABC sequence (airway, breathing, circulation), it is essential to determine the precise level of neurological deficit. Triage scales such as the Alert, responds to Voice, responds to Pain, or Unresponsive (AVPU) Scale can provide a rapid assessment of the patient's responsiveness but not suitable for long follow-up. However, for a more comprehensive evaluation of children with altered consciousness, standard and informative scales like the modified Glasgow Coma Scale (MGCS) or the Blantyre Coma Scale should be employed for regular assessments. These scales offer a more detailed assessment of the patient's neurological status and aid in monitoring changes over time (Njuguna et al., 2008).

A MGCS is the most commonly used tool for assessing the LOC in critically ill children in the PICU. The MGCS contains three parameters eye opening, best verbal response, and best motor response (Temiz et al., 2018). However, there are drawbacks to using the MGCS scale. First, its use is restricted when verbal responses cannot be determined, especially in intubated and aphasic patients. Second, the scale does not include brain stem reflexes. Third, it does take into account the patients’ respiratory pattern. Untimely changes in consciousness associated with deviations in respiratory patterns and brainstem reflexes have not yet been documented (Ramazani & Hosseini, 2019).

The full outline of unresponsiveness (FOUR) Coma Score is an operational tool for evaluating the LOC. The FOUR Coma Scale is easy to learn and apply, and this 16-point scale excludes the verbal component of the GCS and instead includes the brainstem reflexes and respiratory patterns. The FOUR Coma Scale was first validated in a neurological-neurosurgical ICU with a good predictor of hospital mortality, and 3-month outcome in children with coma (Czaikowski et al., 2014; Jamal et al., 2017; Wijdicks et al., 2005). In order to make the right clinical decisions regarding early diagnosis, treatment, and prognosis, it is important to select an appropriate diagnostic instrument. Therefore, to assess the LOC in children, the FOUR Coma Scale was recently developed and recommended as an adjustment for the GCS (Wijdicks et al., 2005). It is necessary for PICUs nurses to correctly assess LOC to detect neurological changes and initiate immediate action.

Review of Literature

The GCS is a commonly used tool to objectively measure the LOC of children in the PICU. It uses a total of three levels scoring system to obtain the LOC. The highest GCS score of 15 indicates fully awake and ability to be oriented, and the lowest score of 3 indicates complete unresponsiveness (Vahdati et al., 2017). However, the applicability of the GCS is limited. It cannot identify subtle clinical changes in comatose children it does not account for important clinical conditions such as, brainstem reflexes and respiratory patterns (including mechanical ventilation) to determine the LOC (Wijdicks et al., 2005). In addition, the GCS cannot assess verbal responses, making it difficult for the PICU nurses to establish an accurate score. Therefore, the LOC reported in these children is lower than the actual level. Additionally, a 10-year retrospective study concluded that the GCS could not predict the outcome of children with traumatic brain injury (TBI) (Peng et al., 2015).

The association between admission coma score and eventual outcome was assessed using Morray Coma Scale developed for children with various central nervous system injuries. In contrast to the GCS, this scale does not require verbal cues for assessment and thus can be applied to preverbal or previously intubated children. Cortical function was graded from six (purposeful, spontaneous movements) to zero (flaccid), and brainstem function was graded from three (intact) to zero (absent and apneic). The maximum total score was nine (Morray et al., 1984).

The Mayo Clinic designed the FOUR Coma Scale in 2005. The accuracy and precision of this scale in critically ill children has been evaluated in few studies only. The FOUR Coma Scale is a new validated scale that is clinically validated to evaluate altered LOC in critically ill children (Ghelichkhani et al., 2018; Jamal et al., 2017).

The FOUR Coma Scale evaluates four neurological functions: eye response, motor response, brainstem reflexes, and respiratory patterns (including mechanical ventilation). The four categories were scored from 0 to 4 points, with a score of 4 representing normal and a score of 0 indicating no response (Peng et al., 2015). This scale is recommended by the latest guidelines of the European Society of Intensive Care Medicine (ESICM) (Sharshar et al., 2014) and is a better diagnostic tool for assessing cirrhotic and pediatric patients, and for predicting the outcome of patients after cardiac arrest and TBI (Mouri et al., 2015).

The PICU nurses are responsible for the continuous assessment of critically ill children. One of the main obstacles encountered during their assessment is neurological dysfunction, especially in comatose children. Assessment of the LOC is the most important first step in neurological examinations in the PICU. A quick and accurate assessment minimizes neurological complications, unnecessary diagnostic procedures, and mortality and morbidity rates. The basic requirement for any assessment to be effective is the availability of an objective, valid, reliable, and accurate tool (Al-Quraan & Eid AbuRuz, 2016). The FOUR Coma Scale is a reliable component of nursing care for the complete neurological assessment of critically ill children. Hence, it is essential for PICU nurses to have knowledge and skills about using the FOUR Coma Scale neurological assessments.

In the PICU, the assessment of LOC for critically ill children is essential for nurses’ roles and responsibilities. Unfortunately, many studies have been conducted to assess the knowledge of nurses and other clinicians about the GCS, and have reported poor knowledge of this important tool. However, nurses need to use an accurate assessment scale with no barriers to determine the LOC in children for planning and implementing appropriate care. Therefore, selecting an appropriate diagnostic instrument to assess LOC in children is essential to make correct clinical decisions regarding early diagnosis, medical care, and prognosis. Moreover, a study conducted by Shalaby et al. (2019) to compare the FOUR Coma Scale and MGCS in predicting discharge outcomes of altered consciousness patients and recommended that the FOUR Coma Scale was a reliable measure of assessing neurological status and predicting the outcome of altered LOC patients. To comprehensively assess the impact of educating nurses about the FOUR Coma Scale, further research is warranted, particularly in larger PICUs with varying nurse-to-patient ratios and different nurses’ educational level as well as different nursing education methods. This research should aim to evaluate the effects on nurses’ practice and the ease of interpreting the LOC using the scale. It is crucial that the FOUR Coma Scale is thoroughly understood and utilized accurately to ensure its effectiveness in clinical practice. Therefore, it is necessary to improve and update PICU nurses’ knowledge and practices. Few studies have been conducted to assess nurses’ perceptions of the FOUR Coma Scale. These studies recommended that training sessions were significantly effective in improving PICU nurses’ performance and perception regarding the FOUR scale compared to the GCS (Abd Elrazek Baraka & Shalaby, 2021; Bamani, 2021; Yglesias & Suson, 2020). For these reasons, this study aimed to improve pediatric critical care nurses’ practice in implementing the FOUR Coma Scale. The following research objective was assessed: first: Assessment of the nurses’ knowledge and practice about FOUR Coma Scale. Second objective is to apply and appraise new FOUR Coma Scale on PICU. The third one is to evaluate the effectiveness of implementing educational intervention to enhance nurses’ knowledge and practice of the FOUR Coma Scale

Methods

Research Design and Setting

The research design employed in this study was a quasi-experimental research design specifically a one-group (pre/post-test design). The study was conducted at the Medical Pediatric Intensive Care Unit affiliated with Mansoura University Children's Hospital, Mansoura University, Egypt. The PICU provides services to critically ill children. The ratio of nurses to pediatric patients in these units was 2:1 during the morning shift. However, the ratio differed during the afternoon and night shifts, with a ratio of 1:2.

Research Question—Hypothesis

1. What is the level of nurses’ knowledge and practice about FOUR Coma Scale?

2. What are the most common barriers reported by nurses for assessment of LOC in children?

3. Implementing an educational intervention significantly improves the knowledge and practices of nurses regarding the implementation of the FOUR Coma Scale in the PICU.

Sample Inclusion/Exclusion Criteria

The current study was carried out on a convenience sample composed of 45 male and female nurses who were involved in providing nursing care for critically ill children working in the PICU for up to one year, The nurses voluntarily participated in the study, and signed informed consents. The total number of nurses working on PICU is 60 nurse 57 female and 3 males. Some of them are in maternity leave. The working shift in the PICU divided into three shifts (morning from 8.00 am to 2.00 pm, afternoon from 2.00 pm to 8.00 pm and the night shift from 8.00 pm till 8.00 am).

Data Collection Tools

Two tools were formulated to collect data pertinent to the study. Tool I is “FOUR Coma Scale knowledge assessment questionnaire.” This tool was designed by the researchers after reviewing recent literature and seeking advice from experts to assess nurses’ knowledge of the new FOUR Coma Scale (Jamal et al., 2017; Santos et al., 2016; Singh et al., 2016; Wijdicks et al., 2005). The tool was divided into three parts. Part I: included nurses’ characteristics such as age, qualification, years of experience in the PICU, and the method usually used in the PICU to assess LOC. Part II: included questions about the FOUR Coma Scale (definition, components, indications, LOC assessment, subscale assessment, nurses’ precautions before assessment of LOC, interpretation scores) in the form of multiple-choice questions (MCQ). In the third part of the study, nurses were asked to provide their perceptions regarding barriers they encountered when assessing the LOC. This was done using a four-point Likert scale, where participants could indicate their level of agreement on a scale ranging from “strongly agree” to “strongly disagree.” Nurses that had scores ≥80% were considered to have good knowledge, nurses scores <80% to ≥75% were considered to have average knowledge, and Scores <75% were considered to have poor knowledge (Alhassan et al., 2019).

Tool II is “FOUR Coma Scale observational checklist.” This tool was adopted from Wijdicks et al. (2005) to assess nurses’ practices while using the FOUR Coma Scale in the PICU. It consists of 20 steps, divided into eye responses, motor responses, brainstem reflexes, and respiratory patterns. Each item consists of five steps. Every step given a score on the bases of “Done” and “Not done.” Done scored a point, and not done scored zero points. The marks scores assigned for each step were calculated to obtain a total maximum score of 20. Total scoring of ≥80% was considered competent, and scores >80% was considered incompetent (Alhassan et al., 2019).

Validity and Reliability

The tool's content validity was assessed by five experts from the pediatric critical care nursing and medicine. The reliability of tool I was (Cronbach's alpha = 0.89). The inter-rater reliability of tool II FOUR Coma Scale observational checklist was excellent the score was (kW 0.82; 95% CI, 0.77– 0.88) as it was reported in the original article. A pilot study was conducted to check the clarity, feasibility, applicability, and objectivity of the data-collection tools. It involved five nurses (10%) of the total sample. No further modifications were required.

Procedures

Data collection occurred over a period of 6 months, spanning from April 2020 to October 2020. The collection methods employed consisted of structured observations and the utilization of self-reported questionnaires. These methods were implemented in three distinct phases: the assessment phase, the implementation phase and the evaluation phase. In the assessment phase, an explanation of the study objectives and processes was provided to the head nurse and the nursing staff in the PICU. The researchers attempted to build trusting relationships and maintain a relaxed atmosphere for the nurses to gain their cooperation and interest. The researchers used Tool I to assess nurses’ knowledge of the FOUR Coma Scale, and collected their characteristic data. Each nurse was assigned a number as a code for identification during the study. The researchers used Tool II during direct observation of each nurse during the practice sessions with children, on an average of 3 hours per day, three times per week for 1 month. The researchers developed an educational intervention that included theoretical and practical sessions using different references related to the FOUR Coma Scale. After completion, the researchers sent the educational intervention to five experts in pediatric and critical care nursing & medicine to evaluate the content validity of the program.

In the implementation phase, the instructional FOUR Coma Scale program was provided for two months by the researchers in three sessions per week, and every session was carried out for 40 to 60 min in the morning and afternoon shifts. The nurses were divided into nine groups. The theory session focused on introduction to FOUR Coma Scale, definition, causes and management of coma, severity, FOUR scale purpose, component, steps and scoring system, assessment of critically ill children, and nursing management strategies for children. In addition, the theoretical session also addresses the common errors or challenges that nurses may encounter when implementing the scale and provide strategies to overcome them. There were three sessions for the theoretical part of 50 minutes each. Prior to the start of each session, the researchers engaged in brainstorming activities and posed questions to the nurses to assess their retention of the previous session's instructions and reinforce their knowledge.

Practical sessions were delivered through 10 training sessions. Each practical session lasted 60 minutes during the working shift to facilitate the meeting. It focused on the following items: assessment LOC, how to perform the FOUR Coma Scale steps, and demonstration of the FOUR Coma Scale in children in the PICU. In addition, the practical session also addresses the common errors or challenges that nurses may encounter when implementing the scale and provide strategies to overcome them. Sufficient time was given for discussions, clarifications of any questions regarding practical skills, and displaying simple training using video training about the FOUR Coma Scale application. Subsequently, the researchers periodically observed the nurses’ bedside practices regarding the application of the FOUR Coma Scale to ensure proper skills and safe practice.

To improve pediatric critical care nurses’ practice in implementing the FOUR Coma Scale, a comprehensive learning activity were designed and utilized. First, use case studies and real-life scenarios to demonstrate the application of the FOUR Coma Scale in pediatric critical care settings using real pediatric patient cases. Second, group discussions and case reviews to encourage nurses to share their experiences, challenges, and best practices related to implementing the FOUR Coma Scale. This interactive session encourages collaborative learning and allowing nurses to learn from each other's insights and perspectives. Third, the researchers benefited from peer learning and mentoring among nurses. Pair experienced nurses with those who are less familiar with the FOUR Coma Scale to facilitate knowledge sharing and provide support. As well, the researcher also prepare booklet about FOUR Coma Scale in English and Arabic version and give for nurses to ensure ongoing learning.

In the evaluation phase, 2 months after the implementation of the FOUR Coma Scale educational intervention. The researchers evaluated the nurses’ knowledge and practice using the FOUR Coma Scale (post-test). Treatment fidelity was assured as the researchers developed an educational intervention booklet about the FOUR Coma Scale that included all the information required by the nurses, and educational posters were made available.

Ethical Considerations

Ethical approval was obtained from the Committee of Research Ethics of the Faculty of Nursing, Mansoura University with Ref No (P.0486). Before conducting the study, official acceptance was obtained from the manager of the Children's Hospital and the manager of the PICU, who was one of the researchers. Before starting the study, the researchers explained the purpose and processes. Informed consent was obtained from all the nurses. Nurses were assured that they had the right to withdraw from the study at any point. Confidentiality of participants information was ensured.

Statistical Analysis

Data were analyzed using SPSS version 24. Normality of data was tested using a one-sample Kolmogorov–Smirnov test. This test is commonly used to assess whether a dataset follows a normal distribution. By conducting this test, the researcher can determine if the assumptions of certain statistical tests are met. Categorical variables are presented as frequency and percentages. The associations between categorical variable were tested using the Chi-square, McNamara tests. The Monte Carlo test used when the expected cell count was < 5. Continuous variables are presented as mean ± SD (standard deviation). Two-group comparisons were performed using paired t-tests. Pearson's correlation coefficient was used to correlate continuous data. The P-value was significant at P < .05.

Results

Sample Characteristics

Table 1 presents the nurses’ characteristics in percentage distribution. Most of the nurses (94.6%) in this study were female, the mean age was 33.02 ± 5.52 years. Less than half of nurses (40%) had10 to 15 years of experience, mean was 10.26 ± 4.39 years. The same table represents that the majority of nurses (71.1%) had bachelors’ degree of nursing education, and more than half of them (55.6%) reported that Moray Coma Scale was the most commonly used tool in the PICU to assess LOC.

Table 1.

Characteristics of the Studied Nurses in Percentage Distribution (N = 45).

Characteristics	Mean ± SD	Minimum– Maximum
Age in years	33.02 ± 5.52	22–42
	NO (n = 45)	%
Gender
Male	2	4.4
Female	43	95.6
Qualification
Diploma	7	15.6
Technical institute of nursing	6	13.3
Bachelor degree of nursing	32	71.1
Years of experience
≤5	10	22.2
5 ≤ 10	15	33.4
10 ≤ 15	18	40
15 and more	2	4.4
Mean ± SD		10.26 ± 4.39
Scales usually used in the PICU to assess LOC a
Modified Glasgow	20	44.4
Moray	25	55.6

^a Numbers are not mutually exclusive.

Study Hypothesis and Research Question Results

There were statistically significant differences in the nurses’ knowledge of using the FOUR Coma Scale (Table 2). More than half of nurses (55.5%) did not know the indication of FOUR Coma Scale in the pre-intervention phase. However, majority of the nurses (86.7% and 91.1%) were more aware of the indication and component of scale in the post implementation phase. Moreover, less than half of nurses (46.6%) reported that they assessed the presence of endotracheal intubation and eyelid edema. This percentage was improved to 68.8%. Approximately a quarter of nurses (20% and 24.4%) were aware about pupil and corneal reflex in the pre-test but the percentage improved post-test (75.6% and 66.7%, respectively).

Table 2.

Nurses Knowledge About FOUR Coma Scale (N = 45).

Variable	Pre-intervention		2-Month post-intervention		Test of sig. (P-value)
	No. (45)	%	No. (45)	%
The indication for using FOUR Coma Scale
Locate brain tumor	3	6.6	2	4.4	MC <.001**
Assess the depth of coma	12	26.6	39	86.7
Monitor the extent of meningitis	5	20	4	8.9
Do not know	25	55.5	0	0
Main items of FOUR Coma Scale
Eye opening, verbal response, motor response	19	42.2	4	8.9	MC <.001**
Eye opening, respiratory pattern, motor response	5	11.1	0	0
Eye opening, respiratory pattern, pupil response	9	20	0	0
Eye opening, motor response, respiration, brain stem reflexes	12	26.7	41	91.1
The nurse should do the following before assessing the conscious level #
Presence of endotracheal intubation and eyelid edema	21	46.6	31	68.8	MC .033*
Respiratory and hemodynamic stability	15	33.3	18	40	MC .512
Use of sedatives and neuromuscular blocker	16	35.5	25	55.5	MC .057
The FOUR Coma Scale is used to assess the level of consciousness for intubated patient's
True	18	40	40	88.9	MC <.001**
False	27	60	5	11.1
To assess the eye opening the nurse should
Verbally Ask the child to open his/her eyes	8	17.8	17	37.8	MC .118
Call the patient's name out loud	28	62.2	22	48.9
Use painful stimuli	1	2.2	2	4.4
Stand next to the patient's bed	8	17.8	4	8.9
The nurse can assess the motor response through
Verbal command requesting a motor response	22	48.9	33	73.3	MC <.001**
Use of painful stimulus	20	44.4	4	8.9
Observe muscle strength	3	6.7	8	17.8
When testing the best motor response, you
Record the response in the best arm	12	26.7	0	0	MC <.001**
Record the response in the worst arm	2	4.4	0	0
Record the best response from the legs	7	15.6	5	11.1
Record the response in all four limbs	24	53.3	40	88.9
To test motor response in a patient (paralyzed in all four limbs) the nurse should —
Inflict a pain stimulus in the arms until there is response	2	4.4	6	13.3	MC .002*
Inflict a pain stimulus in the legs until there is response	14	31.1	2	4.4
Ask the patient to nod or turn his head	29	64.4	37	82.2
Lift the arm up and let it drop to the bed three times	0	0	0	0
To assess the corneal reflex the nurse should
Lightly touch a thin strand of clean cotton to the patient cornea and observe for blinking and tearing in that eye	9	20	34	75.6	χ2 = 31.85 <.001**
Ask the child to open and close his eye	9	20	7	15.6
Do not know	27	60	4	8.9
To assess the pupil, reflex the nurse should
Move the torchlight from the side of the head towards the pupil and observe any change in pupil size and the speed of the reaction (brisk or sluggish)	11	24.5	30	66.7	χ2 = 17.06 <.001**
Use clean cotton and touch the patient cornea and observe for blinking	15	33.3	9	20
Do not know	19	42.2	6	13.3

MC: Monte Carlo test; χ²: Chi-squared test.

*P < .05.

**P < .001.

There were statistically significant differences in the nurses’ knowledge of the interpretation of the Coma Scale scoring system. As shown in Table 3, 26.7% of nurses were familiar with the total score of FOUR Coma Scale pre-test implementation which increased to 80.0% in the post-test period. Additionally, in a quarter of the nurses (26.7%) who gave the correct answer to the lowest score of the Coma Scale during pre-test implementation improved to 75.6 post-test implementation. Only 4.4% of nurses knew the score that showed critical situation in pre implementation while, 91.1% of them identified it in the post-test implementation. A two-third (68.9%) of nurses could estimate the most adequate response on the Coma Scale in pre-test increased to three quarter (75.6%) post-test.

Table 3.

Nurses Knowledge About the Interpretation of Scoring System of FOUR Coma Scale (N = 45).

Variable	Pre-intervention		2-Month post-intervention		P-Value
	No. (45)	%	No. (45)	%
The total score of FOUR Coma Scale
12	21	46.7	0	0	χ2 = 33.42 (<.001*)
15	12	26.7	9	20.0
16	12	26.7	36	80.0
The lowest score of the Glasgow Coma Scale is
1	22	48.9	9	20.0	MC (<.001*)
3	12	26.7	34	75.6
4	9	20.0	2	4.4
10	2	4.4	0	0
The score that shows critical situation and the nurse should be alert to and notify the doctor is –
≤7	22	48.9	0	0	χ2 = 68.93 (<.001*)
≤3	21	46.7	4	8.9
≤8	2	4.4	41	91.1
≤10	0	0	0	0
The nurse can judge the most adequate response for score is —–
The first response presented by the patient	14	31.1	8	17.8	MC (.078)
Best response presented by the patient	31	68.9	34	75.6
Last response presented by the patient	0	0	3	6.7

MC: Monte Carlo test, χ²: Chi-squared test.

*P < .05.

**P < .001.

Table 4 presents data on the implementation of the FOUR Coma Scale by nurses in the PICU. It includes information about specific steps of the scale and whether they were performed by the nurses. The results show that the nurses’ practice concerning eye response was good in the pre- and post-test intervention phases, as 77.8% of nurses correctly observed the eye response step in pre-test intervention compared to all nurses (100%) in post-test intervention. The nurses’ practices concerning motor assessment, brainstem reflexes, and respiratory patters were poor in the pre-test intervention and there was an apparent significant improvement post-test intervention. This percentage decreased to 86.7% after the intervention. The differences were statistically significant (P < .001).

Table 4.

Nurses’ Observational Checklist About Implementation of FOUR Coma Scale in PICU.

Steps	Pre-intervention				2-Month post-intervention				Test of significance #	P-Value
	Done		Not done		Done		Not done
	No.	%	No.	%	No.	%	No.	%
Eye response
Stands beside the child bed and moving and observe the Eyelids open or opened, tracking, or blinking to command	35	77.8	10	22.2	45	100	0	0	χ2 = 11.25	*<.001*
Observe Eyelids open but not tracking	26	57.8	19	42.2	35	77.8	10	22.2	χ2 = 4.12	.042*
Call the child and check Eyelids closed but open to loud voice	45	100	0	0	45	100	0	0		1.0
Do any painful stimuli and observe the Eyelids closed but open to pain	40	88.9	5	11.1	45	100	0	0		.056
Eyelids remain closed with pain	40	88.9	5	11.1	45	100	0	0		.056
Motor response
Thumbs-up, fist, or peace sign	0	0	45	100	39	86.7	6	13.3	χ2 = 72.0	*<.001*
Localizing to pain	6	13.3	39	86.7	42	93.3	3	6.7	χ2 = 57.85	<.001**
Flexion response to pain	6	13.3	39	86.7	44	97.8	1	2.2	χ2 = 64.98	<.001**
Extension response to pain	6	13.3	39	86.7	45	100	0	0	χ2 = 68.82	<.001**
No response to pain or generalized myoclonus status	38	84.4	7	15.6	45	100	0	0		.026*
Brainstem reflexes
Pupil and corneal reflexes present	8	17.8	37	82.2	38	84.4	7	15.6	χ2 = 40.02	<.001**
One pupil wide and fixed	6	13.3	39	86.7	38	84.4	7	15.6	χ2 = 45.53	<.001**
Pupil or corneal reflexes absent	7	15.6	38	84.4	39	86.7	6	13.3	χ2 = 45.53	<.001**
Pupil and corneal reflexes absent	4	8.9	41	91.1	39	86.7	6	39	χ2 = 54.55	<.001**
Absent pupil, corneal, and cough reflex	3	6.7	42	93.3	42	93.3	3	11.1	χ2 = 67.60	<.001**
Respiration
Not intubated, regular breathing pattern	6	13.3	39	86.7	37	82.2	8	17.8	χ2 = 42.79	<.001**
Not intubated, Cheyne–Stokes breathing pattern	9	20	36	80	38	84.4	7	15.6	χ2 = 37.45	<.001**
Not intubated, irregular breathing	10	22.2	35	77.8	40	88.9	5	11.1	χ2 = 40.5	<.001**
Breathes above ventilator rate	6	13.3	39	86.7	40	88.9	5	11.1	χ2 = 51.40	<.001**
Breathes at ventilator rate or apnea	12	26.7	33	73.3	42	93.3	3	11.1	χ2 = 41.66	<.001**

MC: Monte Carlo test, χ²: Chi-squared test.

*P < .05.

**P < .001.

Table 5 presents the nurses’ total knowledge and practice score about the FOUR Coma Scale. It was observed that the mean score of total knowledge about FOUR Coma Scale was 5.64 ± 1.79 pre-test implementation, and the mean score was improved to 11.49 ± 1.50 post-test implementation, and the difference was statistically significant. Additionally, the mean score of the total level of practice for the FOUR Coma Scale was 21.69 ± 1.43 pre-test implementation which improved to 33.02 ± 4.12 post-test implementation, and the difference was statistically significant (P < .001).

Table 5.

Nurses Total Knowledge and Practice Score About FOUR Coma Scale (N = 45).

Item	Pre-intervention		2-Month post-intervention		P1
	No.	%	No.	%
Good ≥ 80%	0	0.0	24	53.3	MC <.001**
Average ≥ 75%–< 80%	0	0.0	12	26.7
Poor < 75%	45	100.0	9	20.0
Mean ± SD	5.64 ± 1.79		11.49 ± 1.50		t = 16.58 P =< .001**
Nurses total practice score
Competent practice ≥ 80%	0	0.0	39	86.7
Incompetent practice ≤ 80%	45	100	6	13.3
Mean ± SD	21.69 ± 1.43		33.02 ± 4.12		t = 16.42 P =< .001**

MC: Monte Carlo test, t: paired t-test.

**P < .001.

There was a positive correlation between the total knowledge and practice scores, as shown in Table 6 and Figure 1 (r = .680), and the difference was statistically significant (P < .001).

Table 6.

Correlation Between Total Knowledge Scores and Total Practice Scores.

Item	r	P
Practice scores	.680	<.001*

*Pearson correlation.

Figure 1.

Scatter diagram for positive correlation between knowledge and practice score.

Figure 2 shows the self-reported barriers by nurses for assessing the LOC in PICU. Majority of nurses (75.6%) were stated that a lack of training and education, and a lack of hospital policy to assess LOC (66.7%) were the most common barriers for implementing and assessing the LOC in PICU.

Figure 2.

Nurses self-reported barriers for assessing the level of consciousness in PICU.

Discussion

The FOUR Coma Scale is the most widely used scale for assessing consciousness, particularly in intubated children. Assessment of the LOC is essential for proper treatment and intervention plans for critically ill children to do so, mostly scoring tools are used. Many studies have assessed the validity, reliability, applicability, and accuracy of the FOUR Coma Scale in assessing the LOC in children in the PICU (Almojuela et al., 2019; Pandwar et al., 2022; Jamal et al. 2017). However, few studies have been conducted to educate nurses about the FOUR Coma Scale (Abd Elrazek Baraka & Shalaby, 2021; Bamani, 2021; Yglesias & Suson, 2020) as a standardized tool for assessing the LOC in PICU. In this study, the researchers used instructions intervention to improve PICU nurses’ knowledge and practice regarding the assessment of the LOC using the FOUR Coma Scale.

This study showed that the nurses had good knowledge about the actions and assessment needed to be performed before assessment of LOC, assessment related to motor response, and how the nurses assess patients’ response to the FOUR Coma Scale score. In addition, nurses reported good practice scores in the assessment of eye opening. A low level of knowledge and practice was evident in the main items of the FOUR Coma Scale; assessment, implementation, and interpretation of corneal and pupil reflex, FOUR Coma Total Score and critical score (that needed urgent care). The current study showed that more than half of the nurses responded that the Moray Coma Scale was the most common scale used in the PICU to assess LOC in children, followed by the GCS, but not all nurses were aware of the FOUR Coma Scale. This may be because this is a newly validated tool not implemented in the PICU, and is not commonly used in the PICU.

The study showed that the nurses had poor knowledge and the minority of them replied correctly regarding the indication, main item of the FOUR Coma Scale, importance, and interpretation of the score (total and critical score that need urgent care) before the intervention training. A previous study by Abd Elrazek Baraka and Shalaby (2021) has reported that nurses were more knowledgeable about GCS than the FOUR scale before conducting the training sessions, and this knowledge improved after the training session This finding is contrary to that reported by Santos et al. (2016) who showed that the majority of nurses (more than 80%) gave correct answers when questions were related to the GCS. The researchers believe that the difference in the results could be attributed to the fact that the FOUR Coma Scale is a relatively new scale, and few nurses were aware of that tool.

The first study conducted by Cohen (2009) confirmed that the FOUR coma score and GCS were comparable in predicting outcomes in critically ill children. Therefore, implementing the FOUR score may improve the ability to accurately predict survival and the impact of treatment and management on children and their families. This finding is similar to that reported by another study conducted by Khajeh et al. (2014).

The study findings revealed that there were statistically significant differences in nurses’ knowledge of the interpretation of the FOUR Coma Scale scoring system. The knowledge and practice levels appeared to improve after the implementation of the instructional intervention. These findings are similar to that reported by Vink et al. (2018), who showed that nurses’ assessment of LOC might be improved with instructional training (based on several factors, such as the number of patients with altered consciousness, teaching skills, and workload). Therefore, this study recommends more systematic training approach, including classroom teaching and e-learning, in addition to bedside training.

The present study identified five barriers hindering PICU nurses’ assessment of LOC. As reported by nurses, the highest percentage was the lack of training and education, followed by the hospital policy that did not enforce assessment of the LOC, and the workload. A study by Ehwarieme and Anarado (2017) reported that the main perceived factors affecting the use of the GCS by nurses for the assessment of LOC included a lack of continuous training and updating courses on the GCS, lack of documentation charts, lack of adequate knowledge and skill, and excessive workload with few nurses on duty.

The present study showed that the mean score of total level knowledge about FOUR Coma Scale was 5.64 ± 1.79 pre-test implementation which statistically significantly improved to 11.49 ± 1.50 post-test intervention implementation This finding is similar to that reported by Al-Quraan and Eid AbuRuz (2016), who demonstrated that lack of knowledge of the GCS is a global problem. Therefore, Jordanian nurses have inadequate knowledge of GCS applications, and educating nurses, regardless of the area of practice, is mandatory. Another study conducted by Hussein (2015) in Egypt on the use of GCS in the pediatric department showed that nurses had unsatisfactory knowledge about GCS before training but their knowledge scores improved after training.

This study revealed a statistically significant positive correlation between the total knowledge and practice scores. This result was similar to the finding from Hussein (2015) who showed a statistically significant difference in nurses’ practice for the application of the pediatric GCS before and after the application of instructional guidelines. Finally, instructional intervention, continuous education, and updating nurses’ knowledge are considered emergent needs for nurses in the PICU and for all health care teams. This helps nurses update their knowledge level and improve their practice, which in turn will positively improve the quality of care provided to critically ill children and improve the ranking of the hospital.

Strengths, Limitations and Future Work

This study has both strengths and limitations. The first limitation is that some studies implemented the FOUR Coma Scale and nurses’ knowledge and practices prior to this study. But the results of the current study cannot be compared with the other similar studies. Additionally, this study did not measure the effect of educational intervention programs on improving pediatric patient outcomes. Therefore, we recommend that further research is needed to evaluate the effect of education on the FOUR Coma Scale to detect the LOC to improve outcomes and detect complications in critically ill children.

Implications for Practice

This study had highlights four important points. First, the study can help and guide nursing educators and curriculum designers regarding the importance of updating the nursing curriculum to include the FOUR Coma Scale in nursing courses and student sheets. Second, the study can help pediatric critical care physicians understand the importance of conducting more studies on the feasibility, applicability, and effectiveness of the FOUR Coma Scale in assessing LOC in children. In addition, this tool was considered a standard of care for intubated children using the FOUR Coma Scale in all PICU. Third, the findings revealed the importance of continuous nursing education and training in improving nurses’ practice of important and lifesaving tools, such as the FOUR Coma Scale. This study also provides nurses with an easier, more accurate, and comprehensive way to assess the LOC of intubated children. They will also be able to monitor subtle changes in their LOC that may require urgent medical attention. Fourth, good supervision by the head nurse for PICU nurses during the assessment and implementation of the FOUR Coma Scale is important for providing nurses with support, guidance, and trust in their practice. Additionally, an extended training program and e-learning training must be conducted for nurses inside the unit to increase their competency levels. This study helps improve nursing practice by providing knowledge about new tools and scales in the assessment of the LOC in intubated children. Overall, the findings of this study suggest that there was an improvement in nurses’ knowledge of the FOUR Coma Scale after the intervention. However, there were some variations in the scale implementation implying the need for further training and reinforcement of the protocol. It is important to ensure that nurses have a solid understanding of the FOUR Coma Scale and consistently apply it in clinical practice to accurately assess and monitor the LOC in children admitted to the PICU.

Conclusion

In conclusion, The FOUR Coma Scale is an efficient and easy assessment method for assessing LOC in children and can be easily implemented and interpreted by nurses. This study illustrated a significant improvement in the level of nurses’ knowledge and practice regarding the FOUR Coma Scale and represents the importance of continuous education for improving care provided for critically ill children.