Inter-Rater Reliability in the Assessment of Consciousness in Patients Receiving Palliative Care in Intensive Care: A Prospective Cross Sectional Observational Study

Abstract

Background: The Glasgow Coma Scale (GCS) is one of the methods that has validity for evaluating the consciousness levels of patients in the literature and is accepted by health authorities. Aim: The purpose of this study was to evaluate the inter-rater reliability of GCS in intensive care patients receiving palliative care. Study Design: A prospective cross sectional observational study. The study was conducted in a general intensive care unit with 20 beds with patients receiving palliative care. In the unit, 18 nurses worked in two shifts, day and night. Each patient's primary palliative care nurse and two additional researchers were given one minute to independently record the patient's GCS total and subscale scores. All observations were completed within 5min as there could be significant changes in the patient's GCS score during observations. Results: A total of 258 assessments were completed. For the GCS total scoring, a moderate agreement was found between palliative care nurses and the first researcher-observer (49.0%) and also between palliative care nurses and the second researcher-observer (47.7%). In addition, there was a substantial agreement between the first and second researchers (78.9%) and also between all observers (61.5%) (all p=.001). Conclusions: Although there was a near-perfect agreement between the two researcher-observers, we found only moderate agreement among all observers (palliative care nurses and two researcher-observers) in the evaluation of GCS total and subscale scores. Relevance to Clinical Practice: We found that lack of knowledge and training on the standardized use of GCS is still a problem for palliative and intensive care units. Because of the diversity of patients requiring GCS assessment in palliative care units, refresher training programs and hands-on workshops on consciousness assessment should be organized regularly for more experienced nurses.