Joan Pagaduan

Know Your Stroke Scale: Improving Nurses' Assessment Accuracy and Confidence


The project incorporates the National Institutes of Health Stroke Scale in Plain English (NIHSS-PE)1 into the standard assessment and documentation practice for nurses caring for ischemic stroke patients. The aim is to measure the effect of NIHSS-PE on scoring accuracy and confidence among nurses.


This evidence-based practice project addresses challenges faced by nurses using the NIHSS in the neuroscience acute care setting. Despite expertise level, nurses express difficulty scoring assessment with NIHSS2. Within the same department at the same hospital, a substantial score difference between raters was observed3. The simplicity and intuitiveness of the NIHSS-PE enhances workflow and increases scoring accuracy among RNs with varying levels of expertise.


The fellow will: (1) Educate and reinforce neurological assessment techniques using the NIHSS-PE among staff through in-service/bedside teaching, posters, stroke scale laminates, training module, Zoom presentation, and email notifications. (2) Perform real-time patient assessment with staff and compare stroke scale score agreement between primary RN and a designated NIHSS-PE champion. (3) Measure changes in RN’s perceived level of confidence using Gocan and Fisher’s (2008) “Self-Assessed Competency of Neurological Assessment Techniques."


At baseline, the total NIHSS score agreement between the rater and champion during bedside assessment was only at 37.5%. After implementation, total NIHSS score agreement increased to 64%, 58%, and 74% at months 1, 2, and 3, respectively. Marked improvements were found in the following items from baseline to 3 months post-intervention: Visual fields (pre=81.3 %, post=95%), facial palsy (pre=43.8%, post=89%), ataxia (pre=62.5%, post=95%), neglect (pre=87.5%, post=100%).

Pre and post confidence ratings were measured using Benner’s Novice to Expert Model. At baseline, and at 3 months post intervention, nurses self-rated as follows: novice (pre=3%, post=0%), advanced beginner/ competent (pre=44%, post=30%), and proficient/expert (pre=53%, post=70%). The increased competency rating was also evident in the following stroke scale items from baseline to 3 months post-intervention: visual fields (pre=50%, post=72%), facial palsy (pre=53%, post =66%), ataxia (pre=50%, post=62%), and neglect (pre=50%, post=62%).

Conclusions/Implications for Practice:

The project established an overall improvement in score agreement and confidence among nurses with the NIHSS-PE as an educational intervention. It reinforced nurses’ skills and competency on performing neurological assessments. Further studies are needed for application in other areas of care.