CLINICAL ISSUES
Daily observation of cognitive functioning in hospitalised patients on
acute geriatric wards
Anke Persoon, Liesbeth Joosten-Weyn Banningh, Wim van de Vrie, Marcel G M Olde Rikkert and Theo
van Achterberg
Background. Daily observation by nurses of the cognitive function of patients is of high ecological validity because cognitive
functioning is observed in a natural setting around the clock.
Aim. To evaluate why and how geriatric nurses observe the cognitive functioning of their patients.
Design. Survey.
Methods. A self-developed questionnaire was administered to a purposeful sample of nurses working on geriatric wards of seven
acute care hospitals. The questions were open-ended. Data were analysed through content analysis.
Results. The questionnaire was completed by 97 nurses (response rate 77%). Categorisation of the many objectives reported by
the nurses revealed four themes: to tailor nursing interventions (51%), to determine discharge arrangements (46%), to support
medical diagnosis and therapy (43%) and to map specific elements of functional capacity (34%). Nurses reported also many
different domains to observe (mode 2; range 0–7), only 73% of which were actual cognitive domains. The most commonly
mentioned cognitive domain was psychomotor behaviour (63%), followed by executive functions (48%), language (37%),
attention (33%), thinking (25%) and consciousness (20%).
Conclusions. Geriatric nurses not only made daily observations of their patients’ cognitive functioning to support medical diagnoses, but also to guide nursing interventions and determine discharge arrangements. The assessment domains varied fairly widely,
because the participants’ understanding of the concept cognitive functioning was vague, incomplete and often incorrect.
Relevance to clinical practice. This is the first study that investigated why geriatric nurses make daily observations of their
patients’ cognitive functioning. In addition, we explored their understanding of the concept of cognitive functioning. Based on the
fact that the content of an assessment is determined by its aim, the objectives to perform daily observations have to be clear and
stated explicitly. To observe patients in an unambiguous way, it will be necessarrily to develop a validated observation scale.
Key words: assessment, cognitive function, dementia, nurses, nursing diagnosis, observation
Accepted for publication: 10 November 2008
Determination of a patient’s cognitive status is important
because the findings affect the process and outcomes of illness
and treatment (Foreman et al. 2003). This is especially
relevant on acute geriatric hospital wards where patients are
admitted because of multiple health problems: combinations
of somatic, psychological and social complaints. Most of the
Authors: Anke Persoon, MScN, RN, Department of Geriatrics,
Radboud University Nijmegen Medical Centre, Nijmegen, the
Netherlands; Liesbeth Joosten-Weyn Banningh, MSc, Department
of Medical Psychology, Radboud University Nijmegen Medical
Centre, Nijmegen, the Netherlands; Wim van de Vrie, MScN, RN,
Department of Geriatrics, Radboud University Nijmegen Medical
Centre, Nijmegen, the Netherlands; Marcel G M Olde Rikkert, MD,
PhD, Department of Geriatrics, Radboud University Nijmegen
Medical Centre, Nijmegen, the Netherlands; Theo van Achterberg,
PhD, RN, Department of the Centre for Quality of Care Research,
Nursing Science Section, Radboud University Nijmegen Medical
Centre, Nijmegen, the Netherlands
Correspondence: Anke Persoon, Department of Geriatrics 925,
University Medical Centre Nijmegen, PO Box 9101, 6500 HB
Nijmegen, the Netherlands. Telephone: 00 31 24 361 6772.
E-mail: a.persoon@ger.umcn.nl
Introduction
1930
Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1930–1936
doi: 10.1111/j.1365-2702.2009.02811.x
Daily observation of cognitive functioning
Clinical issues
patients have some degree of cognitive impairment due
dementia, delirium, or depression.
The term ‘cognition’ has many interpretations. Often, the
definition refers to the work by Lezak et al. (2004) who
defined it as an information-handling process that covers
the whole process of an individual’s capacity to perceive,
register, store, retrieve and use information (Foreman et al.
2003, Lezak et al. 2004). Comprehensive assessment of
cognitive status encompasses physical and neurological
examination, medical history, functional status assessment
and cognitive testing (Langley 2000). Many instruments
have been developed to assess and evaluate cognitive
functioning in patients. In these instruments, cognition is
commonly broken down into domains that pinpoint
specific areas of impairment (Langley 2000). There is
no uniform way to classify the domains, therefore,
various authors organised the domains in different ways
(Dellasega 1998, Foreman et al. 2003, Gazzaniga et al.
2002, Langley 2000, Lezak et al. 2004). Instruments to
assess cognitive functioning range from full-scale test
batteries that need to be evaluated by neuropsychologists,
to instruments that can be used at the bedside by nurses or
doctors. Some of the inventories focus on one domain, e.g.
orientation, whereas others assess a spectrum of domains
(Foreman et al. 2003).
One way to gather information about a patient’s cognitive
status is by means of daily observation by nurses. These
observations are made around the clock over several days and
are based on interactions that occur naturally between the
patient and nurse. The patients’ cognitive abilities are
observed in a natural setting, e.g. when taking a bath, having
breakfast, meeting other patients, dining with other patients,
receiving visitors and resting during the night. This type of
information is of high ecological validity, i.e. the findings are
generalisable to other settings (Haynes 2001) because cognitive functioning is observed in a natural setting in contrast to
a created test moment. A patient’s actual performance is
assessed, which completes the information on their cognitive
abilities gathered during interviews and neuropsychological
tests (Milisen et al. 2006). Daily observation of cognitive
functioning is highly valued by nurses and geriatricians and it
forms a major task in geriatric nursing. Multiple observations
do not form a burden on the patients, they are in no way
threatening and they are also a useful means to assess
someone who can no longer understand test instructions, or
cannot communicate effectively, or is uncooperative (Langley
2000).
Remarkably, although there are some observation scales
that provide a quick screening of one or two domains of
cognitive functioning (Helmes et al. 1987, Morris et al.
1994, Spiegel et al. 1991), no comprehensive scale is
available for nurses to observe the severity of cognitive
problems in older patients. In the nursing guideline ‘Assessing Cognitive Function’ from the Hartford Institute, the
authors pointed out that, in contrast to the many neuropsychological tests that are available, daily observation of
cognitive functioning is not standardised and the interpretation of behaviour is variable (Foreman et al. 2003). In
daily practice, this means that individual nurses observe in
their own way and report in free text, without the structure
of a printed assessment form. This procedure is ambiguous
and undermines the reliability and validity of the information nurses obtain. Therefore, we examined the level of
agreement between two nurses in 60 patients (Persoon et al.
2007). The weighted level of agreement was not very
satisfactory: agreement was fair to good in five domains
(attention, orientation, thinking, judgment and language)
but poor in four domains (consciousness, perception, insight
and psychomotor behaviour).
Aims
The aim of this study was to gain insight into how and why
geriatric nurses in the Netherlands observe the daily cognitive
functioning of their patients. The following research questions were addressed:
1 What reasons do geriatric nurses have to observe cognitive
functioning?
2 Which domains of cognitive functioning do geriatric nurses
observe?
3 Do geriatric nurses feel the need to use a standardised
assessment form?
Design
Survey.
Methods
Setting
Dutch geriatric wards in the acute hospital setting were
invited to participate. These wards have an average of 16–24
beds and the mean duration of hospitalisation is reported to
be 17–24 days (Huijsman & Zanen 2005). The staff mainly
comprises registered nurses, with some nursing assistants.
Many of the nurses are qualified clinical geriatric nurses.
However, their training does include assessment of their
patient’s cognitive abilities through tests and interviews, but
not through daily observations.
Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1930–1936
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A Persoon et al.
Sample and study procedure
In 2007, the registered nurses working on the geriatric wards
at seven hospitals eligible were for inclusion. These seven
hospitals (out of 25 hospitals with a geriatric ward in the
Netherlands) were selected as a purposeful sample to
represent the variety of geriatric departments in acute care
in the Netherlands, namely: different parts of the Netherlands, two university hospitals and five teaching hospitals and
experience in delirium assessment (two hospitals with completed delirium projects, five with no extra delirium projects).
The head nurse invited all the nurses to participate in the
study, with the exception of nurses on holiday, nurses on duty
(and thus not able to attend the special meeting) and those
absent due to sick leave. We found that 127 nurses were
eligible. A meeting was organised by the head nurse at which
all the present nurses completed the questionnaire.
Data gathering and data analysis
To obtain information, we developed our own questionnaire.
All the questions, except for one, were open ended. Data were
analysed by content analysis, which is a procedure to
quantify communication material according to emerging
themes and concepts (Polit & Beck 2004). As the nurses
were encouraged to give more than one answer, the total
number of objectives could exceed the total number of
respondents.
(a) Objectives
The reasons why the nurse made daily observations of the
cognitive functioning of their patients (objectives) were listed.
No coding scheme was developed beforehand. Then, data
were examined separately by two researchers and units of
contents were developed in an iterative process (first and fifth
author). In this way a coding scheme emerged and quantification became possible (Polit & Beck 2004).
(b) Domains of cognitive functioning
The respondents were asked to describe in their own words
the domains of cognitive functioning that they focused on.
However, in Dutch geriatric nursing, the term ‘domain’ is
not in common use. Therefore, we gave a description of the
domain memory/orientation as example in our questionnaire.
The domains reported by the nurses, were listed and after
that categorised according to an adapted version of ‘Assessing
cognitive functioning’ devised by Foreman et al. (2003). This
model is based on the work by Lezak et al. and this is the only
guideline for nurses on the cognitive functioning of geriatric
patients (2003). The guideline describes the assessment of
1932
cognitive functioning in the context of nursing and it excludes
aspects such as emotions and behaviour, which is in accordance with the Diagnostic and Statistical Manual of mental
disorders/ DSM (APA 2000). In the original guideline, cognitive functioning was divided into the following seven domains: consciousness, attention, perception, memory,
thinking, higher cognitive functioning and psychomotor
behaviour. We changed the name of the domain ‘higher
cognitive functioning’ into the more prevailing term ‘executive functions’ and added the domain ‘language’, because it is
perceived as a cognitive function (see for example the DSM
classification) (APA 2000).
Listing and classification of the nurses’ responses were
performed by two researchers (1st and 2nd author). After
that, data were quantified. However, items which could not
be categorised into the scheme of cognitive domains, were
listed and classified into emerging themes. Furthermore,
relations between the number of correctly described domains
and background variables: hospital variations (type, nursing
care system and number of staff) and variations between the
nurses (experience, education and primary nurse) were
explored using Pearson’s correlation.
(c) Standardised assessment form
Question 3 on whether the nurses felt the need for a standardised assessment form for the daily observation of cognitive
functioning, was dealt with by means of a dichotomous item.
Results
Sample characteristics
A total of 97 nurses completed our self-developed questionnaire (response rate 77%). About two thirds of them were
licensed practical nurses (63%) and one third were registered
nurses (34%). Slightly less than half of the respondents had
five years of experience on a geriatric ward (49%), while the
others were less experienced. A fairly large proportion of the
nurses had specialised in geriatric care (43%), another
subgroup had not taken an advanced course in geriatric
nursing (49%) and the rest were still in geriatric nursing
training (8%). The nurses were employed at university
centres (31%) or general hospitals (69%). More than half
of the nurses (56%) were providing care according to the
model of primary nursing care (four hospitals), while the
others were following a functional nursing model (three
hospitals). Three quarters of the nurses working within the
primary nursing system were actually primary nurses
(n = 42). Per hospital, the number of nurses varied from
0Æ52–1Æ52 full-time equivalent per bed.
Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1930–1936
Daily observation of cognitive functioning
Clinical issues
(a) Objectives
There were several concurrent reasons why the nurses
observed the daily cognitive functioning of their geriatric
patients. The four most commonly mentioned reasons were:
to determine the setting needed after hospitalisation (34%),
to guide behavioural interventions and approaches (27%), to
inform and educate family members (26%) and to help make
a diagnosis (25%) (Table 1, column 2). After categorisation
of all the reasons, four themes emerged (Table 1, column 3).
Three out of the four themes focused on the consequences of
the level of cognitive functioning on the medical and nursing
care. The first theme focused on nursing interventions (51%):
27% intended to incorporate the results of the daily observation into the individual nursing care plan and especially
into the behavioural interventions, while 26% intended to
use the findings to inform, educate and support family
members. The second theme focused on discharge arrangements (46%): 34% of the nurses made judgements about the
setting and care requirements, while 20% made judgements
about the nursing care requirements after discharge. The
third theme focused on the medical diagnosis and therapy
(43%): 25% of the nurses aimed to differentiate between
types of dementia, while 22% aimed to help determine the
therapy.
Table 1 Nurses’ objectives to observe the
cognitive functioning of geriatric in-patients
(n = 97) categorised under four emerging
themes
The fourth theme focused on functional abilities in specific
areas: a patient’s decision-making ability, insight into their
illness and functioning, ability to learn new tasks or new
behaviour, autonomy and legal competence (34%).
(b) Domains of cognitive functioning
The respondents were asked to describe, in their own words,
which domains they considered to be aspects of cognitive
functioning. A total of 420 answers were given that ranged
from 0–10 domains per nurse. We found that 307 descriptions could be classified into one of the cognitive domains of
the adapted framework of Foreman et al. (73%), as shown in
Table 2. The other 113 descriptions did not fit into the
adapted framework (27%), see Table 3.
The nurses mentioned 0–6 cognitive domains (mean = 2Æ5;
mode = 2), with the exclusion of the domain memory,
because this was the example given in the questionnaire.
Two thirds of the nurses observed aspects of the domain
psychomotor behaviour, especially the activities of daily
living and apraxia (62%). Half of the nurses observed aspects
of executive functioning, such as insight, judgement, organising and planning in general (48%). One third of the nurses
observed language, namely language expression (37%),
attention, in particular concentration and performing two
Objectives
On a medical and nursing level
1 Focus on nursing interventions
To guide behavioural interventions,
how to approach a patient
To inform, educate or support family members
To support and coach patients
To prevent health problems
2 Focus on settling discharge arrangements
To determine setting needed after discharge
To determine nursing care needed after discharge
3 Focus on medical diagnosis and therapy
To diagnose disease and type of dementia
To determine therapy
To monitor course of disease and evaluate treatment
On a patient level
4 Focus on functional capacity
To assess independence
To assess insight, decision-making capacity,
legal competence
To understand patient’s behaviour
To assess learning abilities
To assess what can be expected
Objectives %*
Themes %
27
51
26
8
4
34
20
46
25
22
7
43
18
10
34
8
5
5
*Respondents formulated a maximum of three objectives, therefore the total percentage of
objectives could exceed 100%.
Objectives reported in free text were categorised under four emerging themes. As the respondents often formulated more than one objective that fell within the same theme, the total
percentage of nurses per theme was lower than the sum of the separate objectives.
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Domains*
Psychomotor behaviour
Plan, organise, coordinate and perform ADL; apraxia;
psychomotor disorders
Executive functions
Insight into problems, illness and daily functioning;
judgement; organising, structuring and planning
in general; initiative and repetition
Language
Language expression: speaking, talking;,
writing; reading; difficulties
finding the right words; express feelings
Attention and concentration:
Concentration; perform 2 tasks at once
Perception
Recognising objects; agnosias; visual hallucinations
Thinking and reasoning
Reasoning; logical and abstract thinking;
coherent thinking; problem solving;
intellect; delusions; paranoia; obsessions
Consciousness
Alertness; drowsiness
Number
mentioned
Nurses
(%)
72
62
77
48
41
37
38
33
32
31
28
25
19
20
Table 2 Cognitive items (307) described
by geriatric nurses (n = 97) categorised in
cognitive domains according to the
adapted guideline of Foreman et al.
*The domain Memory and orientation was given as an example in the questionnaire and
therefore not reported by the nurses.
Respondents formulated a maximum of six cognitive domain. Therefore the total percentage
over the seven domains could exceed 100%.
Non-cognitive items
Behavioural problems
Confusion, restlessness, disinhibition, agitation at night,
attention seeking, correction and regulation intolerance,
behavioural disorders
Emotions
Agitation, aggression, apathy, fear, feeling lonely, sadness
Specific behaviour due to cognitive disorders:
Loss of decorum, loss of control, confabulation, disguise,
changes in character
Social behaviour
Empathy, social abilities, interacting with environment
Physical complaints
Pain, incontinence, dehydration
Diseases, disorders
Delirium, cerebrovascular accident, depression,
personality disorders, psychosocial disorders
General functioning
Coping, ability to adapt, empathy, autonomous functioning
Biological clock
Disorders in day and night rhythm
Others
tasks at once (33%) and perception (31%). Thinking was
observed by one quarter of the respondents, with items such
as reasoning, logical or abstract thinking and delusions
1934
Number
mentioned
Nurses
(%)*
36
30
17
15
12
10
10
9
6
6
8
5
6
5
5
13
5
10
Table 3 Miscellaneous issues (n = 113)
described by the geriatric nurses (n = 97)
categorised under 9 emerging themes
(25%). The comprehensiveness of the cognitive observation
was only statistically significantly related to the nursing
model: the nurses involved in primary nursing systems
Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1930–1936
Clinical issues
assessed cognitive functioning in more detail than the nurses
working in accordance with a functional model (p < 0Æ05).
The respondents also mentioned 113 issues or items that
could not be classified into the cognitive domains of the
adapted framework of Foreman et al. For example (Table 3):
behavioural problems (30%), emotions (15%), specific disorders related to cognitive functioning (such as loss of control,
loss of decorum, 10%), social behaviour (9%), physical
complaints (6%), diseases and disorders (5%), more general
functioning (such as coping, 5%) and biological clock (5%).
(c) Standardised assessment form
The vast majority of the respondents (89%) indicated that
they would prefer to use a standardised assessment form to
observe daily cognitive functioning.
Discussion
The aim of this study was to gain insight into the daily observation of cognitive functioning by geriatric nurses in the Netherlands. To our knowledge, this is the first study that investigated
nurses’ objectives and the cognitive domains they target.
It appeared that geriatric nurses’ reasons to observe
cognitive functioning were not simple, but twofold and
sometimes even fourfold (question a). The most common
reasons were to settle discharge arrangements, to determine
behavioural interventions, to inform and educate relatives
and to support the diagnosis. Categorisation of the reasons
revealed four themes: to guide nursing interventions, to
organise discharge arrangements, to support the medical
diagnosis and therapy and to map specific elements of
functional capacity. The theme ‘to support the medical
diagnosis’, has been mentioned in the literature, but then
the nurses used (simple) neuropsychological tools to test the
patients. (Dellasega 1998, Flaherty et al. 2003, Foreman et al.
1996, Foreman & Vermeersch 1996, Lang 2001, Langley
2000, Maas 2001, Matteson et al. 1997). Only Foreman et al.
(2003) and Milisen et al. (2006) have drawn attention to
assessment by daily observation as a means to support the
diagnosis. In their reports, they spoke of the importance of
‘informal’ assessments and defined these as structured observations of the interactions between the nurse and the patient.
They probably used the term ‘informal’ because the observations were not made on the basis of a valid observation
scale. Our study demonstrated clearly that the objectives of
many of the nurses were as well to tailor nursing interventions and to settle discharge arrangements. The literature
mentions that mapping of the patient’s remaining cognitive
abilities will help towards the comprehension of his/her
behaviour so that it can be explained or clarified to the
Daily observation of cognitive functioning
patient’s relatives (Milisen et al. 2006). Knowledge of a
patient’s (remaining) cognitive abilities makes is possible
to develop individualised and appropriate plans of care
(Dellasega 1998, Flaherty et al. 2003, Foreman et al. 2003,
Langley 2000, Milisen et al. 2006), to offer environments and
programmes that promote safety and maximise function
(Maas 2001) and to settle discharge arrangements (Dellasega
1998, Langley 2000, Milisen et al. 2006). Our findings
confirmed the focus of attention on these aspects of nursing
practice, but only by half of the nurses.
This study illustrated that the nurses’ conception of
cognitive functioning was vague, incomplete and sometimes
incorrect (research question b). Only three quarters of the
issues they described could be classified into the cognitive
domains of the adapted framework proposed by Foreman
et al. (2003). The others were examples of non-cognitive
issues, such as physical or emotional functioning. Each
cognitive domain was mentioned by 20–62% of the nurses.
Most of the nurses mentioned only two (out of the seven)
domains and were thus missing important elements. This
study confirmed the multiform interpretation of the concept
of cognitive functioning described in the Introduction and
showed that it also applies to geriatric nurses. The diversity of
conceptions among geriatric nurses may be due to the
non-uniformity of definitions in the literature.
Almost all the nurses indicated that they would like to use a
standardised assessment form to observe cognitive functioning (question c). This was hardly surprising in view of the
above-described results. We are confident that it indicates
awareness of too much inter-observer variability between
nurses (Persoon et al. 2007).
The use of open questions in our questionnaire was a strong
point in the methodology of our study although we might have
missed answers which the nurses just forgot to mention by
themselves. However, the open questions decreased the chance
of obtaining socially desirable and we presume it increased the
validity of the data concerning the objectives of the nurses and
the cognitive domains they assessed. As the study sample was
representative and sufficiently large, we believe that our results
can be generalised to all nurses on geriatric hospital wards in
the Netherlands. A limitation of the study was that although we
performed content analysis on the answers to the questionnaires, we did not analyse any practical aspects, e.g. the
contents of the patient files.
In summary, the geriatric nurses not only observed daily
cognitive functioning to support medical diagnoses, but also
and more importantly to guide nursing interventions and
settle discharge arrangements. Their understanding of the
concept of cognitive functioning was vague, incomplete and
sometimes incorrect. There was wide variation in the reasons
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why the nurses observed their patients and in their conceptualisation of cognition.
Relevance to clinical practice
‘Nurses play a pivotal role in the recognition, diagnosis and
care of cognitive decline in older people because they have
significantly, more frequent and continuous contact with the
older and their relatives. They are the obvious persons to
gather information about the cognitive and social functioning
of their patients and to compare relevant details’. (Milisen
et al. 2006, p. 16). To fulfil the role of daily observer in a
professional way, the assessments must be performed systematically, unambiguously, purposefully, objectively and
free from individual interpretation. In our study, we identified flaws in the purposefulness and unambiguousness of the
assessment methods. The quality of the daily observations
can be expected to improve after the ambiguity has been
removed. And the use of an observation scale will contribute
to the profession of geriatric nursing and increase the input of
nurses within the multidisciplinary setting. This leads to the
following two recommendations.
Firstly, the objectives of the daily observation have to be
stated clearly and explicitly by the nursing profession because
the content of an assessment is determined by its aim (Haynes
2001). We found that these objectives had four themes: to
tailor nursing interventions, to determine discharge arrangements, to support medical diagnosis and therapy and to map
specific elements of functional capacity.
Secondly, it is necessary to develop an observation scale. Its
use can be expected to increase the level of agreement
between nurses and help them to meet their objectives more
effectively. In view of the multiple purposes of cognitive
assessment, a comprehensive multidimensional observation
scale is required (Foreman et al. 2003, Haynes 2001). The
question is, how far should the standardisation go? At
present, we can see two possibilities: fairly rough standardisation by asking the nurses to describe their observations per
domain in free text or strict standardisation by giving detailed
descriptions of the items in each domain.
Contributions
Study design: AP, WV, LB; data collection and analysis: AP
and manuscript preparation: AP, MR, TA.
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