Background: Assessing patients' level of consciousness in intensive care units
(ICUs) through Full Outline of Un-Responsiveness (FOUR) scale versus the Glasgow Coma
Scale (GCS) requires critical care nurses' (CCNs) knowledge and skills to detect deterioration
of patients' level of consciousness. Objectives: To evaluate the effect of implementing
training sessions on critical care nurses' performance and perception regarding FOUR scale
compared to GCS and reliability of each one. Research hypotheses: Nurses who attend
training sessions will show a significant improvement in performance of FOUR scale
compared to GCS. Study design: A pretest posttest study design was used in this study.
Method: The study was conducted at seven ICUs at Alexandria Main University Hospital
including; Unit I, Unit II, Unit III, Medical, Respiratory, Neurosurgery, and Emergency
anesthesia ICUs. Subject: A convenient sampling technique of all CCNs (100) and a
purposive sample of adult critically ill patients equivalent to the number of nurses' sample was
used to recruit the participants from previously mentioned CCUs. Results: The implemented
training sessions were significantly effective in increasing CCNs' performance and positive
perception of FOUR scale compared to GCS. There was overall higher inter-rater reliability
regarding FOUR score than that of GCS score Cohen's kappa (0.92 versus 0.81) and 83% of
nurses agreed that FOUR scale is a preferred scale to assess the depth of coma. Conclusion:
training sessions were significantly effective in increasing CCNs' performance and positive
perception regarding FOUR scale compared to GCS. Recommendation: Nursing
administrators should provide continuous training sessions. Manual for procedures is advised
to be distributed to all CCNs including all methods for assessing patients' level of
consciousness (LOC).