Assessment of Nurses’ Knowledge of the Glasgow Coma Scale in a Saudi Tertiary Care Hospital: A Cross-Sectional Study

Abstract

The Glasgow Coma Scale (GCS) is essential for assessing traumatic brain injury and predicting patient outcomes, yet studies indicate that nurses often have only a basic understanding of the GCS. In Saudi Arabia, research on this topic is limited, suggesting a need for improvement in nurses’ GCS knowledge. This study aimed to evaluate the knowledge and proficiency of 199 staff nurses at King Fahd Medical City in Riyadh, Saudi Arabia, regarding GCS usage and to identify the factors impacting their competence. A descriptive, cross-sectional survey was conducted, and the data were analyzed using SPSS version 23.0. The results showed that 81.4% of nurses had an average level of GCS knowledge, with a mean score of 8.8 ± 1.826. Only 13.6% demonstrated good knowledge, while 5% had poor knowledge. A significant correlation was found between GCS knowledge and nurses’ departments (χ2(2) = 19.184, p < 0.001). The study concludes that GCS knowledge among nurses in this Saudi Arabian center is moderate, highlighting the need for continuous education programs to enhance their competence in GCS assessment.

1. Introduction

Nurses regularly perform assessments on neurological patients, with a particular emphasis on evaluating their level of consciousness, which is a fundamental aspect of patient evaluation [1,2]. One of the neurological assessment tools employed for this purpose is the Glasgow Coma Scale (GCS). Teasdale and Jennet introduced the Glasgow Coma Scale (GCS) in 1974, and it continues to be recognized as one of the most dependable and efficient methods for assessing the extent and duration of altered consciousness, particularly in cases of head injuries [3]. The GCS was originally designed to evaluate patients with traumatic brain injuries (TBIs); the GCS gained widespread adoption throughout the 1980s due to its simplicity, reliability, and effectiveness in standardizing patient assessments. Its integration into numerous clinical guidelines and protocols has solidified its role as a fundamental component in neurological evaluation [4].

The GCS assesses the level of consciousness through three key indicators: eye-opening, verbal response, and motor response. Eye-opening is primarily mediated by the reticular activating system, which spans from the brainstem to the cerebral cortex, controlling arousal and wakefulness [5]. The verbal response is associated with the functionality of Broca’s and Wernicke’s areas in the cerebral cortex, which are critical for speech production and comprehension, respectively [6]. Motor response reflects the integrity of motor pathways, including the corticospinal tract, and involves various regions, such as the motor cortex, basal ganglia, and brainstem [3].

In addition to these core indicators, other crucial parameters include vital signs, pupil reactions, and limb movement [7]. The GCS employs a scoring system for patient assessment, with overall scores indicating the level of awareness. A score of 15 represents the highest level, signifying full consciousness and responsiveness, while a score of 3 is the lowest, indicating a loss of consciousness and absence of response [8]. By incorporating an understanding of the specific neural substrates associated with each GCS component, clinicians can better interpret the scale in the context of neurological function and injury.

The use of this tool saw a significant increase in the 1980s, especially after its inclusion by the World Federation of Neurosurgical Societies (WFNS) in its patient grading scale for subarachnoid hemorrhage [7]. Additionally, the first edition of Advanced Trauma and Life Support endorsed its utilization for all trauma patients. Today, the Glasgow Coma Scale (GCS) remains the gold standard for assessing and continually monitoring traumatic brain injuries and other acute neurological conditions. It serves as a guide for injury evaluation, prognosis, and determining the level of consciousness in patients [9].

Several studies have raised concerns about nurses’ lack of knowledge regarding the Glasgow Coma Scale (GCS). A study conducted in India by Teles et al. (2013) aimed to evaluate the effectiveness of a self-instructional module for improving staff nurses’ skills and knowledge in GCS practice for neurological assessment [10]. The study concluded that nurses needed better knowledge of the GCS in their assessments. Specifically, 75% of nurses had average knowledge, while 25% had poor knowledge.

A relevant study conducted in Vietnam to assess nurses’ knowledge and performance in using the GCS at a university hospital revealed low adherence to GCS utilization. Nurses encountered difficulties applying it in their practices due to a lack of knowledge about the scale. Only 42.6% of subjects were able to use the scale properly [9].

This concerning practice of nurses’ inadequate knowledge about such cornerstone tools necessitates an evaluation of the situation in Saudi Arabia. It is important to emphasize the significance of GCS assessment in the study area. The GCS assessment plays a crucial role in the study area of neurology and emergency medicine. It provides a structured, standardized, and objective method to evaluate consciousness levels, aiding in diagnosis, monitoring, communication, prognosis estimation, emergency triage, research, and education. The GCS assessment is indispensable for the comprehensive evaluation and management of patients with neurological conditions, ultimately leading to improved patient care and outcomes.

Therefore, the rationale for this study is based on the limited knowledge available regarding the Glasgow Coma Scale (GCS) among nurses in Saudi Arabia. Given the crucial role of GCS in patient care, it is important to assess and improve the understanding of this tool locally. This study aims to identify knowledge gaps and provide a basis for enhancing nurse training in Saudi Arabia.

2. Methods

2.1. Study Design and Setting

We employed a single-center, cross-sectional study design, utilizing a self-administered questionnaire. The study was conducted at a major referral hospital in Saudi Arabia, which comprises two departments: the Department of Neuroscience and the Department of Rehabilitation. This hospital is known for treating a wide range of cases, including traumatic brain injuries, severe trauma, and serious medical illnesses. Patients are either admitted directly or referred there for treatment. The Neurosciences Department has a bed capacity of 112, while the Rehabilitation Department can accommodate up to 125 beds.

• Population and Sampling:

The study involved 450 nurses, with the sample size calculated as follows:

Sample size = (Z² × p (1 − p)/e²)/1 + (Z² × p(1 − p)/(e² × N))

where: N is the population size, e is the confidence interval, and Z is the Z-score.

The sample size was designed to be manageable in terms of time for data collection and analysis. A convenience sampling approach was applied, with 199 out of 215 eligible nurses participating in the survey. This also explains the rationale for choosing this sample size and outlines the specific departments involved in the study.

• Data Collection Procedure:

We have outlined the process of obtaining ethical approval, distributing the self-administered questionnaires via email, and ensuring participant anonymity. The detailed questionnaire sections cover demographic data, GCS knowledge, and factors associated with GCS application.

• Data Management and Analysis:

The data management process, including using MS Excel and SPSS for analysis, has been clearly described. We also provided information on categorizing knowledge levels and the statistical methods employed to assess associations.

2.2. Data Collection Instrument

The research employs self-administered questionnaires divided into three main sections. These sections are designed to collect information on participants’ demographic characteristics, their exposure to the GCS, and their knowledge of the GCS.

• Section A: Demographic Data Collection includes questions about age group, gender, current employment position, qualifications, highest level of education, and working experience.
• Section B: Knowledge Level of the GCS consists of 15 multiple-choice questions, modified from Mattar, Liaw, and Chan (2013), to assess GCS knowledge among nurses in the NNI and Rehab Departments [11].
• Section C: Factors associated with the application of GCS among nurses: 4 questions on possible factors that affect nurses regarding GCS application. The four questions are informed by the previous literature, particularly from Matter et al. (2013) [11].

Participants’ email addresses were used to distribute the link to an online survey. The questions were selected based on a comprehensive review of the literature [11] and input from experts in the field. We ensured that the questions were relevant and aligned with the study’s objectives. To validate the questionnaire, we conducted a pilot test with a small group of nurses who were similar to our study population. Feedback from this pilot was used to refine the questions for clarity and accuracy.

3. Data Analysis

All data were analyzed using SPSS version 23.0. Data obtained from the GCS survey were organized and processed in MS Excel and then transferred to SPSS for further analysis. Knowledge level of the GCS is assessed using 15 multiple choice questions, modified from (11), to assess the GCS knowledge among nurses in the ER and ICU. The Glasgow Coma Scale assigns numeric values, which range from 1 to 5, for each activity. According to (14), knowledge of GCS can be categorized as poor, average, and good. Each correct score was coded as (1), and the level of knowledge of GCS was graded based on correct responses as follows: poor knowledge (1–5), average knowledge (6–10), and good knowledge (11–15).

Descriptive details of participants’ characteristics were presented, including standard deviation, mean, frequency, and percentage. The correct responses were described in terms of frequency and percentage. The chi-square test was used to analyze categorical data such as the association between GCS knowledge and participants’ characteristics.

4. Ethical Issues

We obtained ethical approval from the Institutional Review Board of King Fahad Medical City (Approval Code: 20-383, Approval Date: 10 March 2024) and provided participants with an approval and consent form outlining the study’s goals and their rights. To protect the participants’ identities, we diligently reviewed each completed questionnaire for accuracy before adding it to subsequent questionnaires. This study was conducted according to international standards of Good Clinical Practice (International Conference on Harmonization guidelines), applicable government regulations, and institutional research policies and procedures. This protocol and any amendments were submitted to a properly constituted independent ethics committee (EC) or institutional review board (IRB), in agreement with local legal prescriptions, for formal approval of the study conduct.

5. Results

5.1. Respondents’ Demographic Profile

As shown in

Table 1. Respondents’ demographic profiles (N = 199).

Demographic Characteristics	N (%)
Age
20–30 years	46 (23.1)
31–40 years	92 (46.2)
>40 years	61 (30.7)
Sex
Female	161 (81.3)
Male	37 (18.7)
Department
NNI	61 (30.7)
REHAB	138 (69.3)
Highest Nursing Education
Diploma	8 (4.1)
Bachelor’s Degree	185 (93.9)
Master’s and above	4 (2.0)
Working Experience
Less than 1 year	7 (3.6)
1–6 years	65 (33.0)
7–14 years	81 (41.1)
15 years and above	44 (22.3)

, the majority of participating nurses (69.3%) were young, i.e., aged between 20 and 40 years, and 81.3% were females. Most participants (69.3%) were from the REHAB hospital. The vast majority (93.9%) of nurses reported holding bachelor’s degrees, and 63.4% had more than six years of working experience.

5.2. Assessment of GCS Knowledge among Nurses (Table 2)

• Purpose of GCS Development:

Nearly 97.5% of nurses reported that the tool was initially devised to assess the depth of a coma.

• Knowledge of Brain Parts Assessed:

83.9% correctly identified the occipital lobe.

38.4% correctly identified the temporal lobe.

61.8% correctly identified the cerebellum as parts assessed.

• Awareness of GCS Components:

96.0% correctly identified the components as “eye-opening, verbal response, motor response”.

75.5% correctly stated that “vital signs are not a component of the Glasgow Coma Scale”.

• Motor Response Knowledge:

Only one respondent knew to record the best response from the legs during motor response testing.

• Motor Response in Tetraplegia Patients:

68.7% of respondents would ask the patient to nod or turn their head when testing the motor response in tetraplegic patients.

• Knowledge of GCS Scores:

93.5% correctly identified a score of 3 as the lowest score on the Glasgow Coma Scale.

42.2% mentioned that patients with a Glasgow Coma Scale score of 8 and below are considered comatose.

• Awareness of Score Changes:

54.6% were aware that a reduction of the Glasgow Coma Scale score to 10 in nursing practice is seen as a deterioration in the level of consciousness and requires informing the medical team.

• Assessment of Intubated Patients:

70.1% of nurses acknowledged that the statement “The Glasgow Coma Scale cannot assess an intubated patient’s level of consciousness” is false.

• Patient Status Assessment:

85.9% of nurses reported that a patient stating they are at their daughter’s condominium when asked about their location is confused.

Only two nurses correctly identified that the patient is obeying commands when the patient is unable to comply with a motor response and the nurse inflicts a pain stimulus.

Only 15.5% of respondents correctly identified an eye response score of C for a patient with swollen eyes who cannot open them when instructed.

Table 2. Descriptive summary of nurses’ responses related to the GCS.

GCS Questions	n (%)
1. The Glasgow Coma Scale was initially devised to:
(a) locate brain tumor	0 (0.0)
(b) assess the depth of coma	193 (97.5)
(c) facilitate care for stroke patient’s	10 (5.1)
(d) monitor the extent of meningitis	6 (3.0)
2. What part of the brain is being assessed when you are assessing eye opening?
(a) Cerebral cortex	21 (10.6)
(b) Occipital lobe	167 (83.9)
(c) Cerebellum	6 (3.0)
(d) Reticular formation	4 (2.0)
(e) Hypothalamus	1 (0.5)
3. Which part of the brain is being assessed when you are assessing verbal response?
(a) Cerebral cortex	55 (27.8)
(b) Occipital lobe	10 (5.1)
(c) Cerebellum	53 (26.8)
(d) Reticular formation	4 (2.0)
(e) Temporal lobe	76 (38.4)
4. Which part of the brain is being assessed when you are assessing motor response?
(a) Occipital lobe	2 (1.0)
(b) Cerebelluma	123 (61.8)
(c) Sensorimotor pathways	57 (28.6)
(d) Dermatomes	1 (0.5)
(e) Reticular formation	16 (8.0)
5. What are the specific sections that comprise the Glasgow Coma Scale?
(a) Eye-opening, verbal response, pupil response	2 (1.0)
(b) Eye-opening, verbal response, limb movement	1 (0.5)
(c) Eye-opening, verbal response, motor response	191 (96.0)
(d) Eye-opening, respiratory pattern, motor response	2 (1.0)
(e) Eye-opening, respiratory pattern, pupil response	3 (1.5)
6. Vital signs are a component of the Glasgow Coma Scale.
(a) False	148 (75.5)
(b) True	48 (24.5)
7. When testing the best motor response, you…
(a) Record the response in the best arm	15 (7.6)
(b) Record the response in the worst arm	6 (3.0)
(c) Record the best response from the legs	1 (0.5)
(d) Record the response in all four limbs	176 (88.9)
8. To test motor response in tetraplegia patients (paralyzed in all four limbs),
(a) Inflict a pain stimulus in the arms until there is a response.	17 (8.7)
(b) Inflict a pain stimulus in the legs until there is a response.	8 (4.1)
(c) Ask the patient to nod or turn his head	134 (68.7)
(d) Lift the arm up and let it drop to the bed three times.	37 (19.0)
9. The lowest score of the Glasgow Coma Scale is…
(a) 1	10 (5.0)
(b) 3a	186 (93.5)
(c) 4	2 (1.0)
(d) 10	1 (0.5)
10. Patients with a Glasgow Coma Scale score of… and below are considered comatose.
(a) 1	3 (1.5)
(b) 3	112 (56.3)
(c) 8a	84 (42.2)
(d) 10	0 (0.0)
11. 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) 1	1 (0.5)
(b) 3	19 (9.7)
(c) 8	69 (35.2)
(d) 10a	107 (54.6)
12. The Glasgow Coma Scale cannot assess intubated patient’s level of consciousness.
(a) False	138 (70.1)
(b) True	59 (29.9)
13. On asking a patient, “Do you know where you are now?” the patient states he is at his daughter’s condominium. He is…
(a) Orientated	27 (13.6)
(b) Confused	171 (85.9)
(c) Producing inappropriate words	0 (0.0)
(d) Producing incomprehensive sound	1 (0.5)
(e) Is not responding	0 (0.0)
14. On assessing a patient’s motor response, he is unable to comply. You inflict a pain stimulus, and he pulls his arm away. He…
(a) Is obeying commands	2 (1.0)
(b) Is localizing pain	154 (77.4)
(c) Has abnormal flexion	30 (15.1)
(d) Has abnormal extension	13 (6.5)
15. You are assessing an RTA (road traffic accident) patient, who has swollen eyes. You instruct him to open his eyes, but he is unable to. The eye response score is…
(a) 4	47 (24.2)
(b) Ca	30 (15.5)
(c) 2	88 (45.4)
(d) 0	30 (15.5)

GCS: Glasgow Coma Scale.

Table 2. Descriptive summary of nurses’ responses related to the GCS.

GCS Questions	n (%)
1. The Glasgow Coma Scale was initially devised to:
(a) locate brain tumor	0 (0.0)
(b) assess the depth of coma	193 (97.5)
(c) facilitate care for stroke patient’s	10 (5.1)
(d) monitor the extent of meningitis	6 (3.0)
2. What part of the brain is being assessed when you are assessing eye opening?
(a) Cerebral cortex	21 (10.6)
(b) Occipital lobe	167 (83.9)
(c) Cerebellum	6 (3.0)
(d) Reticular formation	4 (2.0)
(e) Hypothalamus	1 (0.5)
3. Which part of the brain is being assessed when you are assessing verbal response?
(a) Cerebral cortex	55 (27.8)
(b) Occipital lobe	10 (5.1)
(c) Cerebellum	53 (26.8)
(d) Reticular formation	4 (2.0)
(e) Temporal lobe	76 (38.4)
4. Which part of the brain is being assessed when you are assessing motor response?
(a) Occipital lobe	2 (1.0)
(b) Cerebelluma	123 (61.8)
(c) Sensorimotor pathways	57 (28.6)
(d) Dermatomes	1 (0.5)
(e) Reticular formation	16 (8.0)
5. What are the specific sections that comprise the Glasgow Coma Scale?
(a) Eye-opening, verbal response, pupil response	2 (1.0)
(b) Eye-opening, verbal response, limb movement	1 (0.5)
(c) Eye-opening, verbal response, motor response	191 (96.0)
(d) Eye-opening, respiratory pattern, motor response	2 (1.0)
(e) Eye-opening, respiratory pattern, pupil response	3 (1.5)
6. Vital signs are a component of the Glasgow Coma Scale.
(a) False	148 (75.5)
(b) True	48 (24.5)
7. When testing the best motor response, you…
(a) Record the response in the best arm	15 (7.6)
(b) Record the response in the worst arm	6 (3.0)
(c) Record the best response from the legs	1 (0.5)
(d) Record the response in all four limbs	176 (88.9)
8. To test motor response in tetraplegia patients (paralyzed in all four limbs),
(a) Inflict a pain stimulus in the arms until there is a response.	17 (8.7)
(b) Inflict a pain stimulus in the legs until there is a response.	8 (4.1)
(c) Ask the patient to nod or turn his head	134 (68.7)
(d) Lift the arm up and let it drop to the bed three times.	37 (19.0)
9. The lowest score of the Glasgow Coma Scale is…
(a) 1	10 (5.0)
(b) 3a	186 (93.5)
(c) 4	2 (1.0)
(d) 10	1 (0.5)
10. Patients with a Glasgow Coma Scale score of… and below are considered comatose.
(a) 1	3 (1.5)
(b) 3	112 (56.3)
(c) 8a	84 (42.2)
(d) 10	0 (0.0)
11. 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) 1	1 (0.5)
(b) 3	19 (9.7)
(c) 8	69 (35.2)
(d) 10a	107 (54.6)
12. The Glasgow Coma Scale cannot assess intubated patient’s level of consciousness.
(a) False	138 (70.1)
(b) True	59 (29.9)
13. On asking a patient, “Do you know where you are now?” the patient states he is at his daughter’s condominium. He is…
(a) Orientated	27 (13.6)
(b) Confused	171 (85.9)
(c) Producing inappropriate words	0 (0.0)
(d) Producing incomprehensive sound	1 (0.5)
(e) Is not responding	0 (0.0)
14. On assessing a patient’s motor response, he is unable to comply. You inflict a pain stimulus, and he pulls his arm away. He…
(a) Is obeying commands	2 (1.0)
(b) Is localizing pain	154 (77.4)
(c) Has abnormal flexion	30 (15.1)
(d) Has abnormal extension	13 (6.5)
15. You are assessing an RTA (road traffic accident) patient, who has swollen eyes. You instruct him to open his eyes, but he is unable to. The eye response score is…
(a) 4	47 (24.2)
(b) Ca	30 (15.5)
(c) 2	88 (45.4)
(d) 0	30 (15.5)

GCS: Glasgow Coma Scale.

Overall, 13.6% of respondents demonstrated good knowledge of the GCS, scoring between 11 and 15 points. As shown in Figure 1 (

Table 3. Summary of participants’ levels of knowledge.

		Frequency	Percent	Valid Percent
Valid	Poor	10	5.0	5.0
	Average	162	81.4	81.4
	Good	27	13.6	13.6
	Total	199	100.0	100.0

), the majority (81.4%) of respondents possessed an average level of knowledge, with an average score of 8.80 ± 1.826, ranging from a minimum score of 6 to a maximum score of 10, while 5.0% of nurses had poor knowledge in assessing the GCS.

Factors Associated with the Application of the GCS Among Nurses (

Table 4. Factors associated with GCS application among nurses.

Factors	n (%)
1. Do you think it is important to assess and record a GCS for every patient who has altered mental status?
● Strongly disagree	4 (2.0)
● Disagree	2 (1.0)
● Neither agree nor disagree	3 (1.5)
● Agree	33 (16.6)
● Strongly agree	157 (78.9)
2. handover to other nurses include reporting the GCS?
● No	5 (2.5)
● Yes	193 (97.5)
3. Please list below patient conditions for which you would assess using GCS.
● pre/post operation	29 (14.6)
● brain trauma	26 (13.1)
● neuro cases	25 (12.6)
● all admitted patients	18 (9.0)
● stroke	18 (9.0)
● RTA	16 (8.0)
● brain injury	14 (7.0)
● post sedation	10 (5.0)
● TBI	10 (5.0)
● Other (intubated patient, brain tumor, change of level of consciousness, meningitis, post-seizure, confused patients, ICU, old patients, comatose, acute medical, altered mental status, hypoglycemic patient, infection, tetraplegia, unresponsive patient, brain ca, CVA, poisoning, sudden deterioration, after fall, aspiration pneumonia on tracheal tube, brain abscess, Cardiac, chemotherapy, Conscience, cranial fracture, craniotomy, critical care patient, diabetic patients, dizziness, drug abuse, EM, inpatients, ischemic stroke, non-traumatic coma, oncology patients, OR, overdose, patients with EVD, SAH, SCL, spinal cord injury, TB, TBA, tracheostomy, vehicle accident, with EVD, and with TNP)	49 (56.3)
4. Please list ALL the factors that make it difficult for you to assess your patients by using the GCS
● intubated patient	32 (16.1)
● under sedation	31 (15.6)
● language/culture barrier	29 (14.6)
● agitated patients	26 (13.1)
● hearing loss/deaf	20 (10.1)
● mental disorder	14 (7.0)
● patient with h tracheostomy	13 (6.5)
● uncooperative patient	13 (6.5)
● aphasic patients	8 (4.0)
● neurological deficit	8 (4.0)
● Other (cranial fracture, no response, speech impairment, intellectual deficit, age, cognitive impairment, drug intoxication, geriatric, spinal cord injury, alcohol intoxication, brain trauma, post coma, psychiatric patient, psychotic patient, TBI, development delay, dysphasia, post-operation, ventilated patient, amputee, blind, brain anomaly, brain injury, cerebral palsy, communication, confused patient, dementia, difficult patient, disease process, dysphagia, edema, fall, familiarization of the scoring, family and patient cooperation, intoxicated patients, level of consciousness, long stay ICU, mentally challenge, multiple fractures, not following command, not obey to order, paralysis, pediatric, post craniotomy patient, post ICU, SCL, swollen eye, swelling, tetrarch-tony, tetraplegia, and under alcohol)	116 (58.3)

):

• Importance of GCS Assessment:

95.5% of respondents believe it is important to assess and record a GCS for every patient with an altered mental status.

• Reporting GCS in Handover:

97.5% of nurses report the GCS during their normal handover to other nurses.

• Patient Conditions for GCS Assessment:

83.4% of respondents listed top patient conditions for the GCS assessment, including pre-/post-operation, brain trauma, neuro cases, all admitted patients, stroke, RTA, brain injury, post-sedation, and TBI.

56.3% mentioned other conditions, as listed in Table 4.

• Factors Making GCS Assessment Difficult:

97.5% of respondents cited factors that make it difficult to assess patients using the GCS, including intubated patients, those under sedation, language/culture barriers, agitated patients, hearing loss/deafness, mental disorders, patients with tracheostomies, uncooperative patients, aphasic patients, and patients with neurological deficits.

58.3% of respondents mentioned other factors, as listed in Table 4.

This structured format makes the information easier to follow and provides a clear summary of the responses related to factors associated with the application of the GCS among nurses.

Chi-square tests were conducted to examine the significant associations between nurses’ knowledge and their demographic characteristics, and the results are presented in

Table 5. Relationship between respondents’ demographics and their knowledge level of the GCS (N = 199).

Demographic Characteristics	Knowledge Level			Chi-Square Test
	Poor	Average	Good	χ2	df	p-Value
Age
20–30 years	1 (2.2)	37 (80.4)	8 (17.4)	4.561	4	0.335
31–40 years	5 (5.4)	79 (85.9)	8 (8.7)
>40 years	4 (6.6)	46 (75.4)	11 (18.0)
Sex
Female	9 (5.6)	128 (79.5)	24 (14.9)	1.864	2	0.394
Male	1 (2.7)	33 (89.2)	3 (8.1)
Department
NNI	2 (3.3)	41 (67.2)	18 (29.5)	19.184	2	<0.001
REHAB	8 (5.8)	121 (87.7)	9 (6.5)
Highest Nursing Education
Diploma	1 (12.5)	6 (75.0)	1 (12.5)	2.058	4	0.725
Bachelor’s Degree	8 (4.3)	152 (82.2)	25 (13.5)
Master’s and above	-	4 (100.0)	-
Working Experience
Less than 1 year	-	6 (85.7)	1 (14.3)	6.337	6	0.386
1–6 years	2 (3.1)	57 (87.7)	6 (9.2)
7–14 years	3 (3.7)	68 (84.0)	10 (12.3)
15 years and above	4 (9.1)	31 (70.5)	9 (20.5)

. The findings indicated a significant relationship between nurses’ knowledge and their department (χ²⁽²⁾ = 19.184, p < 0.001). Specifically, nurses in the National Neuroscience Institute (NNI) demonstrated significantly higher knowledge levels, with 29.5% of NNI nurses reaching a good level of knowledge, in contrast to nurses in the REHAB hospital, where only 6.5% achieved a good level of knowledge.

6. Discussion

The Glasgow Coma Scale (GCS) is widely regarded as the gold standard for evaluating consciousness and coma levels [10]. However, despite its widespread use, there remain areas of uncertainty and misunderstanding, particularly in terms of inter-rater reliability, tool completeness, and the most effective methods for eliciting eye-opening and optimal motor responses [12]. A study utilizing video recordings demonstrated that healthcare practitioners, including nurses, often struggle with accurate GCS scoring, with nurses achieving an accuracy rate of only 29%, the lowest among healthcare professionals [13].

Our study reveals that staff nurses in Saudi Arabia have a moderate level of knowledge regarding GCS assessment, with 81.4% of the participants displaying average knowledge. This finding aligns with Teles et al. (2013), who similarly observed that 75% of nurses had only an average understanding of the GCS [10]. This trend is consistent with other studies that have reported comparable levels of knowledge among nurses [14]. Additionally, some research has indicated that a significant proportion of nurses possess a low level of expertise in GCS assessment [15,16,17,18,19].

Interestingly, the correlation between nurses’ educational attainment and their GCS knowledge varies across studies. While Albougami (2019) found that nurses with postgraduate degrees had a better understanding of the GCS than those with diplomas or bachelor’s degrees [20], our findings did not support this association. This discrepancy is echoed by Matthias (2015), who found that postgraduate nurses did not necessarily perform more accurate assessments than their counterparts with lower qualifications [21]. These inconsistencies suggest a need for further research to explore the impact of educational attainment on GCS knowledge.

Another significant finding from our study is the variations in GCS knowledge across different nursing departments. Nurses in the Neurosciences Department demonstrated significantly higher levels of GCS knowledge compared to those in the Rehabilitation Unit, likely due to their frequent exposure to patients requiring GCS monitoring. This supports the observations of Mattar, Liaw, and Chan (2013), who noted that ICU nurses, who regularly work with neurologically compromised patients, perform more accurate GCS assessments [11]. Similar patterns have been observed in other studies, where nurses in Neurosurgery ICUs exhibited higher knowledge levels than their peers in other units [18,22,23].

However, our study found no significant relationship between nurses’ GCS knowledge and their years of professional experience, which is consistent with Albougami’s (2019) findings [20]. Despite this, professional development opportunities such as training sessions and workshops remain crucial for enhancing nurses’ skills and ensuring high-quality patient care. According to Shehab et al. (2018), experienced and well-educated nurses are essential for conducting thorough GCS assessments, particularly in critical care settings like the ICU and emergency department [24].

In contrast to studies that have suggested gender differences in GCS knowledge, our research found no significant relationship between gender and GCS understanding [15]. This highlights the importance of focusing on other factors, such as education and department-specific experience, when assessing and improving nurses’ competency in GCS usage.

Our study has limitations, including a small sample size and a single-center design, which may affect the generalizability of our findings. Additionally, the use of convenience sampling could introduce biases, as the sample may not fully represent the broader nursing population, leading to potential selection bias. Consequently, our results should be interpreted with caution. Future research should consider more representative sampling methods, such as random sampling, to improve external validity. Despite these limitations, our study provides valuable insights into GCS knowledge among nurses in this Saudi Arabian center and emphasizes the need for ongoing education and targeted training programs.

7. Conclusions

The study found that staff nurses in a single Saudi Arabian center have moderate expertise in GCS assessment. Nurses in the Neurosciences Department have higher levels of GCS understanding than those in the Rehabilitation Department. At the same time, the levels of GCS knowledge are not affected based on nurses’ education level or professional experience duration. There should be a planned education and frequent training program, as well as a demonstration of how to utilize GCS, so that nurses can precisely monitor the degree of awareness, assuring the patient’s safety.