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Evaluation of the CNS Workshop and Learning Experience
Overall, 94% of participants agreed or strongly agreed that the workshop met their learning needs. More than 93% of participants agreed or strongly agreed that the content of the presentation, the use of demonstration during the presentation, and the case studies presented on the video were helpful. And 99% agreed or strongly agreed that the opportunity to practice in the laboratory setting with feedback was helpful.
Three months after the workshop and implementation of the CNS assessment tool, 88% of nurses reported that the workshop had been helpful or very helpful in contributing to their confidence in performing the CNS assessment. Other learning experiences rated as helpful or very helpful during these 3 months included using the CNS assessment with patients (79%), watching a video/DVD of the CNS assessment (77%), observing role models and peers using the CNS assessment (71%), and receiving feedback on performing the CNS assessment (64%).
Chart Audit
Forty-four charts were audited (Fig 2). Twenty-six patients were appropriate for CNS assessment; in 18 cases (69%) the CNS was used, and in 8 cases (31%) the GCS was used.
Of those cases in which the CNS tool was used, documentation was fully accurate in 6 cases (33%). In the remaining 12 cases, the following was observed: the side of weakness was not identified each time the assessment was done although it always was identified at the first assessment (n = 7); the total score was calculated correctly but recorded in the wrong area (n = 6); dysarthric speech was not identified as slurred (n = 2); and motor testing for a patient with a comprehensive deficit was documented in an incorrect area (n = 1). There were 2 instances in which errors in documentation were potentially clinically important. Although there was a decrease of more than 1 point on the CNS scale in 6 patients, chart documentation of physician notification was present for only 2 of these patients. This may reflect an error in failing to communicate with the medical team, a lack of documentation of communication, or a perception by the nurse performing the assessment that the change was not significant.
Discussion
A limitation of this study was the low response rate at 3 months. The strengths of this study were that the choice regarding which validated stroke scale to use was nurse-initiated and the study included voluntary participation.
The majority of nurses are aware of BPGs; the workshop significantly increased nurses' awareness of BPGs for stroke, and it increased awareness of BPGs in general. This awareness was greater again at 3 months. Although perception of access to BPGs was moderate, the perception did increase over time. The majority of nurses reported that BPGs were valuable in providing care for neuroscience patients, although they were used less and valued less at 3 months after the workshop. Awareness of BPGs does not necessarily reflect a perception of value or of accessibility or actual use. A belief that a practice change is valuable is necessary to sustain change over time. Translating BPGs into bedside practice may require more effort directed at changing and maintaining nurses' perceptions of their value and accessibility and increasing their actual use.
Nurses strongly agreed that they used or would use the CNS assessment immediately after and 3 months after the workshop, although use was slightly less frequent at 3 months after the workshop. Although this finding was not significant, it requires further comment. Nurses may perceive the CNS assessment on its own as an incomplete assessment of a patient's neurological status. The CNS assessment scores only the weaker side, and in patients with a comprehensive deficit it identifies only an asymmetry. Details of the degree of weakness or bilateral weakness are not captured; consequently, nurses must document their neurological assessment in another manner. Stroke assessment tools do not replace neurological assessments; they should be used in conjunction with them. Nurses also said the CNS was not a tool they found useful for communicating the status of patients with stroke to other team members. Physicians at this study center are more familiar with the GCS or the NIHSS scoring system, and reports of changes in the CNS score may have been more difficult to interpret.
The CNS was implemented not only for patients with ischemic stroke and intracerebral hemorrhage but also for those with subarachnoid hemorrhage to determine whether the tool provided a more useful assessment of neurological function. Nurses reported that, in the case of a patient with subarachnoid hemorrhage, they often switched between the CNS and the GCS because the patients' level of consciousness changed. There were 5 patients with subarachnoid hemorrhage in the chart review, and, although they were deemed appropriate for CNS assessment, the GCS was used in all instances. Verbal feedback from nurses during the implementation identified that, although these patients could be awake or drowsy, they often fluctuated in their ability to participate in the entire CNS assessment, particularly with hourly assessments. This is consistent with the findings reported by Doerksen, Naimark, and Tate (2002) and Doerksen, Naimark, and Tate (2004), in which the NIHSS was implemented with patients with subarachnoid hemorrhage.
In general, nurses were confident in performing the CNS assessment. When the components of the scale were subdivided, nurses were very confident in assessing level of consciousness and orientation. They also were confident in assessing aphasia and motor function, but there was more variation in confidence assessing these components over time. At 3 months after the workshop, although the nurses were confident in performing the CNS assessment and they used the CNS in practice, they mildly disagreed with the statement that the CNS was easy to use. This may indicate that it could take more than 3 months to assimilate a change in practice. Informal feedback included the comment that patients often tired of the same frequent physical assessments and questions and that solely identifying motor asymmetry for patients with receptive aphasia constituted an incomplete assessment. There was a significant decrease in the number of respondents at 3 months (34% response rate), and this group may reflect the opinions of nurses who had more difficulty using the tool. Richardson, Murray, House, and Lowenkopf (2006) reported that nurses were more comfortable using the NIHSS after an education and implementation program; however, they did not explore whether the nurses found the tool easy to use. In this same study, the percentage of nurses who reported that the NIHSS took too much time remained similar before and after implementation (24% and 21%, respectively). The study conducted by Richardson and colleagues (2006) involved fewer nurses, participation was mandatory, the study was not blinded, and ethics approval was not reported.
BPGs for stroke recommend the use of a validated stroke assessment tool, yet there are no clear recommendations or evidence to guide the frequency of using these tools. Hourly neurological assessments are common in the acute-stroke period, and the CNS or NIHSS may take too much time for bedside nurses to use frequently. Although an assessment using a validated stroke tool represents best practice, it is not necessarily relevant practice at all times. It may be more reasonable to use a stroke assessment tool upon admission and then every 4-12 hours or when nurses detect a change during a standard neurological assessment.
Nurses rated the CNS workshop as very helpful, especially the laboratory practice and feedback segments. At 3 months, the majority of nurses considered the workshop to be the most helpful learning experience that contributed to their confidence. This is consistent with Bandura's Self Efficacy Theory, which identifies the opportunity to practice with feedback as the strongest contributor to confidence. Centers that wish to implement a new stroke assessment tool should consider offering a workshop that includes the opportunity to practice as part of the implementation. Educators often rely on video and didactic presentations of stroke assessment scales, but these do not allow for valuable interaction that can be experienced only when performing the CNS assessment with opportunities for feedback.
Recommendations
Nurse awareness of BPGs is high; however, nurses are less likely to find BPGs accessible or easy to translate into practice. The use of BPGs in practice was less frequent at 3 months. It is important to consider several factors when implementing a validated stroke assessment scale as identified in BPGs for stroke care. The education phase should include an opportunity for nurses to practice the assessment and receive feedback so they can gain confidence in using the tool. The educational approach used in this study was identified by the nurses as helpful and resulted in increased confidence in performing the CNS assessment that was sustained over time.
The implementation phase should include the opportunity for reinforcement of education and feedback on issues encountered with using the tool in nursing practice. Using feedback from nurses, we are in the process of revising the bedside documentation record, reviewing the need for hourly use of the CNS tool in the acute stroke phase, and developing "neurological assessment nursing rounds" to be conducted every 2-4 weeks to provide immediate feedback on assessments. The nursing round is of particular significance to address staff turnover and the subsequent educational needs.
Any neurological assessment tool has limitations. The advantages of the CNS assessment are that it can be performed in less than 5 minutes, and it assesses language and facial and proximal- and distal-limb motor strength. But the CNS scores only the motor strength of the weakest limb, and for patients with a comprehensive deficit, it scores only an asymmetry in limb strength. When assessing motor strength, nurses involved with this study did not consider the CNS assessment suited to a subgroup of stroke patients with comprehensive deficit. To address the limitations identified by nurses in this study, our center is in the process of revising the bedside documentation record to include not only the CNS but also an additional section in which to document bilateral upper- and lower-extremity power. Nurses use the bedside record to document their neurological assessment and communicate with their colleagues; consequently, it should reflect a more thorough examination, particularly for patients with a comprehensive deficit. Perhaps BPGs should be viewed as templates that require adjustment and refinement so they can work in specific settings.
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