Joumal of Advanced Nursing, 1994,20,881-884

Knowledge and level of consciousness:

application to nursing practice
Nigel Ingram BSc(Hons) RGN
Lecturer/Practitioner, Lancashire College of Nursing and Health Studies, and
Neuroscience Directorate, Royal Preston Hospital, Preston, Lancashire, England

Accepted for pubhcabon 3 February 1994

INGRAM N (1994) Journal of Advanced Nursing 20, 881-884

Knowledge and level of consciousness* applicabon to nursing practice
Assessing a patient's level of consciousness is a skilled part of nursing practice
The epistemology of this activity is discussed using the four patterns of
knowing identified by Carper It is suggested that all four patterns and their
mteraction are necessary for a practitioner to be able to carry out this activity
with the necessary reliability and accuracy that good safe practice dictates A
possible enhancement to how a practitioner gams this knowledge can be
through the work of )oint appointments, between education and clinical areas

in nursing and is seen as being an extension to the tra-

ASSESSING THE LEVEL OF
ditional art vs science debate (Guilding 1993), whereby
CONSCIOUSNESS
nursing practice has been categorized, often forcibly, into
A common element of many nurses' daily practice is to either camp Carper identified the following patterns of
assess the level of consciousness of their patients It may knowing, (a) empmcs, (b) aesthetics, (c) personal and
be a purposeful activity which requires the recording of (d) ethics
their findings, or it may be earned out almost without
thinking, with the nurse only becoming aware when a
Empincal knowledge
result other than normal is obtained The formalized
assessment tools, which will be discussed later, are Carper (1978) described empincs as being the science of
included at all levels of nurse training, yet they are only nursmg, whereby facts are organized into laws and theory
refined when an emphasis is placed upon their use, such This follows the more traditional model, such as medicine
as m specialized neurological centres As a nurse trained being a 'hard' science, which has developed towards a
m neuroscience nursmg and mvolved in the training of single paradigm status, yet she suggests that nursing
other specialized nurses, it is of interest to me to explore should develop 'a body of empincal knowledge specific to
how nurses approach this part of their practice and m nursmg' Empincal knowledge should therefore be based
particular the type of knowledge required not only to carry on research using factual evidence and statistical data
out the assessment reliably and accurately, but also to be (Guilding 1993) Therefore how does this apply to the
able to act upon its results assessment of a patient's level of consciousness'
The empincal knowledge required by a nurse mcludes
levels of anatomy and physiology of the brain This will
NURSING KNOWLEDGE
form the basis upon which a judgement about how and
Many authors, such as Eraut (1985) and Inglis (1985), why the level of consciousness could change From this
have discussed knowledge creation and the relationship level of understanding the nurse is able to request and
between theory and expenence, but it is the work by interpret data Prior to 1974 there was no widely recog-
Carper (1978) which will form the basis of my discussion nized standard way m which a patient's level of cons-
This work identified four fundamental patterns of knowmg ciousness wEis assessed and for this information to be
communicated This changed with the milestone paper by
Correspondence Nigel Ingram 9 Norfolk Road Walton-le-Dale, Preston, Teasdale & Jennett (1974) who had devized the Glasgow
Lancashire PR5 4GB England Coma Scale This scale took three prmciple areas of

881
 N Ingram
l)ehaviour — namely eye-opemng, verbal response and
best motor response — and organized them m an order
which represented dysfunction When the resultsfi-omall
three areas are combmed, a measure of the patient's level
of consciousness is obtained This scale was presented m
a format which was designed to be easy to use, concise yet
provide a visual representation about the patient
Glasgow Coma Scale
The Glasgow Coma Scale (GCS) now forms the inter-
national standard and as such it is the most widely used
form of assessment taught to nurses (Frawley 1990) It
allows for a uniform approach to gain factual evidence and
IS incorporated mto all neurological assessment charts
used in the United Kingdom, yet often may not used m a
correct or accurate way (Watson et al 1992)
A small-scale study was reported by Crewe & Lye (1990)
They asked 10 nurses (a sister, a staff nurse and eight stud-
ent nur8es) who worked on acute medical wards about the
GCS and its implementation Three students claimed never
to have heard about any coma scale Two nurses suggested
that 'responsiveness' was the most important aspect of an
assessment of the level of consciousness, whereas five sug-
gested that the blood pressure is the most important obser-
vation (none of the vital signs are incorporated withm a
coma scale) Seven respondents claimed not to have any
knowledge to assess the level of consciousness and five
did not feel they were competent to do so
Does the level of empincal knowledge effect the
reliability and accuracy of the Glasgow Coma Scale' A
junior student nurse may be able to follow the scale but
may misinterpret some of its sections, for example charting
'inappropriate words' rather than 'orientated' because the
patient had sworn at her This would suggest that training
in the use of the GCS should include how to mterpret
vanous responses A study by Rowley & Fielding (1991)
explored this further by companng expenenced agamst
inexperienced users They concluded that expenenced
nurses used to the scale were the most consistent and
reliable, and that inexperienced nurses were liable to make
consistent errors, particularly when the patient was at an
intermediate level of consciousness and thus liable to give
misleading mformation
Thus the level of a nurse's expenence is recognized
as being an important factor which suggests that the
nurse needs something more than just empincal
knowledge
Aesthetic knowledge
Aesthetics represents the art of nursing, or that element
which does not encompass the hard facts of science, but
rather the more personal, creative side of knowledge
Meerabeau (1992) and Benner (1984) use terms such as
'tacit knowledge' and 'know-how' when refemng to nurses
882
who use knowledge created from and emt)edded withm
their practice £k)es this mean that expenenced nurses are
able to he more consistent and rehable users of the GCS
because they are ahle to refer hack to knowledge gamed
from previous patients' This would suggest that they are
able to create a more accurate impression of what level of
consciousness a patient is at This is demonstrated usmg
the results from the Rowley & Fieldmg (1991) study An
inexpenenced nurse may easily he able to distinguish
between one fully conscious patient and another who is
in a deep coma, but when it is necessary to distinguish
between subtle changes, errors occur as the nurse is unable
to match the change with past experience
A reported source of error m using the GCS is that of
one observer followmg the results of another (Frawley
1990) This occurs when the nurse making the assessment
IS unable to interpret the results, or is unwilling to accept
that a chai\ge may have taken place, and as a result will
often record the results based on the previous findings
rather than as a result of her or his own assessment It may
be the case that nurses are unable to express their findings
withm the confines of the categories within the GCS, but
that through expenence concem is felt for their patients
but they are unable to express it
Intuition
Beimer & Tanner (1987) descnbe how more expert nurses
use the expression of intuition vwthm their practice This
they define as 'xmderstandmg without a rationale' and
state that it compnses six key elements, pattern recogni-
tion, similarity recognition, common-sense understanding,
skilled know-how, sense of salience and deliberative
rationality These key elements are discussed below
Pattern recognition This is the ability to recognize pat-
terns of responses For expert nurses this occurs m their
ability to detect subtle changes in levels of consciousness
without resorting to the GCS, although it may form the
basis upon whicb they recognize the patterns, for example,
a patient who requires a louder verbal command to open
their eyes subsequently becoming less conscious
Similarity recognition This often occurs when a patient
remmds a nurse of a previous expenence and clearly could
be a factor in how a nurse interprets the results of an
assessment However, it should not be a factor m how a
nurse cames out the assessment, which should be geared
to the individual patient
Common-sense understanding This allows a nurse to
apply the basics of a neurological assessment in diffenng
circumstances For example, many paediatnc units have
developed their own versions of the GCS (although some
still use the adult scale even on small children), thus
allowmg for the prmciples of the GCS to be maintained
 Assessing level ofconxiousn^s

Skilled know-how When a nurse is able to detect or even standpomt having had a different background and expen-
predict a change m the level of consciousness whilst at ences This can often happen m clinical practice where
the same tune controlling for other factors, such as nsmg the queshon, 'What do you think''' serves to recc^ize the
mtarcramai pressure, then often the nurse is making a unique nature of the individual and the contnbuhon he
skilled judgement without making precise observations or she may bnng
This could he descnlied as using different sources of The personal knowledge of each nurse will reflect m
knowledge to make an informed judgement how they assess the levels of consciousness of a patient
The personal knowledge may suggest that observations are
Sense of salience Although the Glasgow Coma Scale can carried out more frequently, or more attenhon is paid to a
t>e used to make a judgement about a patient's level of particular pomt Undertaking observahons every 15
consciousness, some observahons can stand out m their minutes may seem difficult to a junior nurse who can take
level of importance to which an expert nurse will relate up to 15 minutes to complete each set, whereas an experi-
For example, assessment of a pahent's pupils' reaction to enced nurse will rationalize the assessment mto a parhcu-
light IS commonly earned out, but when one pupil sud- lar order, being able to anticipate complications or events
denly dilates and becomes fixed to light this will alert the
nurse to a senous situahon Reflective practice
It can be very difficult to teach this level of personal knowl-
Deliberative rationality In many specialties, practitioners edge to junior staff, but through the realm of clinical prac-
can often gam a narrow view of a situation For example, tice each nurse can adapt and expand upon their own
a pahent's level of consciousness detenorates and often a understanding The use of reflechve prachce is one method
neuroscience trained nurse will only rationalize a neuro- now bemg taught as a means of expanding personal
logical explanation without considenng the 20 or so other knowledge
possible non-neurologieal causes Reflechve practice enables nurses to analyse past expen-
These six elements serve to show that mtuition plays an ences which have some level of meaning to them It may
important part m aesthetic knowledge creahon, hut that be negative or posihve, but by askmg individuals to evalu-
offen It IS diflBcult to divide clearly between empmc and ate crihcally those actions of themselves and others, areas
aesthehc forms of knowledge Carper (1978) suggests that of knowledge are identified This may lead nurses to
whilst empmcs is recogmtion, aesthetics is about the nurse explore the acquisition of new knowledge, which in turn
having perception and having empathy with his or her will influence how they approach future events
patient This leads on to the third pattem of knowing,
personal knowledge
Ethical knowledge
The last domain of nursmg knowledge as descnbed by
Personal knowledge Carper (1978) is that of ethical/moral knowledge Through-
Although descnbed as a separate pattem of knowing, per- out climcal practice, nurses are t>eir^ asked to make
sonal knowledge is very difficult to separate from the other choices, often needing to recognize the moral judgement
three Carper (1978) explores the idea that the healing bemg placed upon the outcome of that choice In a neuro-
nature of a nurse—patient relahonship can be enhanced by surgical umt, terminal patients who are m a coma are nursed
the nurse being aware of the 'therapeutic use of self Being An ethical decision offen needs to he made as to the
able to extend the knowing of one's own bemg to that of fi«quency of neurological assessment m order to assess the
another serves to strive towards a greater understanding best verbal and motor responses, as this requires the mflic-
of the patient as an 'integrated, open system incorporating hon of pam A balance needs to he made between the needs
movement toward growth and human potential' This level of the pahent against the needs of the nurse A conflict
of knowledge will by its very nature he different for every between medical and nursing staff could arise, often con-
nurse as they understand and interpret each situation cerning the use of morphine What is the balance between
In order for nurses to be able to gain an insight not only the need of the pahent to be pam-free against that of a drug
into their own nature but also that of their relahonship wtuch can influence the results of a neurological assessment
with a pahent, it is necessary to build upon all the other and thus the basis for potential therapy'' By tieu:^ a pahent's
forms of knowledge The way in which mdividual nurses advocate, the nurse needs to answer these queshons, which
understand empineal information, combining with the includes beu^ able to decide the ethical posihon
mtuihon and experienee of aestheties, allows them to
bring fresh insight to a situation As a lecturer/prachtioner Ethical judgement
I have been asked by a ward sister to help assess a particu- To be able to make an ethical judgement, the nurse must
lar patient I may not have brought any parhcular new skill use empineal and aesthehc knowledge Is it ethical for
to the situahon, but was able to review from a different those nurses m Crewe & Lye's study (1990) to be canng

883
 N Ingram
for head-injured patients when they lack the empincal
knowledge to do so^
An ethical obligation is placed upon practitioners to
carry out safe and competent practice by being aware of
the research basis to their practice This will mclude not
using outdated techniques, such as a 'sternal mb', to gener-
ate pain as ttus can cause substantial bruismg over the
stemum, rather to use a trapezius pinch or to press a pencil
agam8t the side of a fingemail bed
CONCLUSION
Many neurological textbooks, when covenng the subject
of assessing a patient's level of consciousness, do so from
a purely empirical standpoint by discussing the Glasgow
Coma Scale Whilst it is recognized that this is an integral
part of this subject, the knowledge necessary for a prac-
titioner to fulfil this aspect of his or her practice extends
beyond the purely empirical How this knowledge is cre-
ated and then diffused throughout the realm of practice
needs to be considered Whilst the empirical knowledge
can be gained via textbooks and purely theoretical class-
room teaching, it is clear that other forms of knowledge
are necessary to compliment the purely empincal
Where the boundary lies between empincal and aesthet-
ics IS not clear, as is so often the case when considenng
art vs science Does the expenence of compeirmg qualified
nurses on an acute medical ward vs those m a specialist
neuroscience imit suggest that only by specializing can
general practice be refined through the interaction of aes-
thetic and empirical knowledge' The role of personal and
ethical knowledge must also be considered, as they are
important elements m how a nurse arrives at a judgement
This ability to make an informed judgement encompasses
all four ldenUfied pattems of knowing, as well as their
interactions
Knowledge creation
Eraut (1985) asks, 'To what extent is professional knowl-
edge created by research or in practice, and what is the
relationship between the facilitation of knowledge cre-
ation and the promotion of knowledge use'' Research gen-
erated the GCS but it was only through practice (both
medical and nursing) that the scale was refined, e g from
14 points to 15 Work by Watson et al (1992) produced
not an alteration to the scale but more of a senes of 'guide-
lines' m Its use The mterplay between research and prac-
tice results m the generation of theory but, ais Guilding
(1993) points out, there is an 'inconsistency with which
individuals interpret theory' but that research (empirics)
combined with guidelines (aesthetics/personal) allows for
the delivery of individualized holistic nursing care
Carper (1978) suggests that the teachmg of any one
pattern of knowledge should not be at the expense of any
884
other Should the Glasgow Coma Scale be routinely t a i ^ t
to student nurses, m a classroom setting, who may then
m turn not be able to apply it accurately, or should it be
taught m a practical context, thus allowmg for the combi-
nation of empmcal and aesthetic knowledge' This practice
IS now the norm with the advent of Project 2000
Supervision of junior staff
In the climcal situation, there needs to be a system of
supervision whereby new junior staff, who have not devel-
oped a level of aesthetic knowledge, need to be fostered
Clinical supervision therefore should bnng together
expenenced practitioners so that practice will inform prac-
tice There is also a need for expenenced practitioners to
have a role withm theory generation as well as the teaching
of theory Jomt appointment posts between practice and
education have been developed as a way of facilitating this
process By having a formalized role vnthm the two areas,
the nurse can allow for each to inform each other, thus
aiding the diffusion of all four forms of knowledge
The assessment of a patient's level of consciousness is
one area of nursmg practice whereby all four pattems of
knowledge are brought together, which allows the prac-
titioner to make an informed decision towards the patient's
care It is important that the nurse should recognize the
interplay between these different pattems of knowmg, and
thus areas of strengths as well as weakness
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