Nurse Care for the Cognitively Impaired-The Role of NVC.

Cognitive Impairment and Nurse care

Communication is the pulse of nursing practice. Communication barriers of the mentally and cognitively impaired patients seem to erode the quality of nursing care. Lack of nurse-patient interaction due to patient’s cognitive impairment affects nurse assessment of the patient and the medication adherence. Studies to elucidate the effects of cognitive impairment on the reliability of nurse assessments to explore the relationship between cognitive status and reliability of multidimensional assessment data have proved that the reliability of the patient’s communication and sensory ability are affected by cognitive status (Phillips, 1993). The major factor contributing to the disadvantage has been the inadequacy in training of nurses in associated communication skills. Other factors include the patient’s concealing their disability, work pressure and poor communication of the nurses. Communication with the cognitively impaired is complex with different aspects of perception and practice. Studies on such cognitively impaired patients to evaluate the time care givers provide for direct patient care have showed that more time is being spent with normal patients than with the affected (Sirkka, 1996). Non-speaking patients are the worst affected and it is important to improve their communication to allow them receive care and comfort. Use of non-verbal communication skills (NVC) to improve nursing care, especially with mentally ill and cognitively impaired people seems to be the key to nursing care in such settings.

The nurse’s problems in care

 Studies on communication with cognitively impaired patients by the health care professionals have shown that care of such patients need clear communication during care procedures.  But, the patient’s inability to provide an accurate history of his problem and to participate in self-care blocks the usual process of care, often resulting in medical uncertainty, inadequacy and frustration for the nurse (Wendy, 2005).  The negative influence of elderly patient’s mental impairment on patient interaction documented in a study using the Clifton Assessment Procedure (Armstrong et, al 1986) with 23 patients under three categories of lucid, slightly confused and demented has shown that health care professionals interact less with confused category them lucid category. A phenomenological study conducted to describe the nursing students' experiences caring for cognitively impaired with thirty-seven undergraduate nursing students using Colaizzi's phenomenological method of analysis has shown emotions such as frustration, sadness, fear and empathy among nurses (Brereton, 1995).

Most of the health care professionals are more directed in the physical care of the patients than the psychological interaction or restorative activity. A recent small scale pilot study exploring the educational base and needs of qualified care givers with reference to patients with learning disability has shown the lack of knowledge and skills in health care professionals to deal with these patients.  The study has also recommended the introduction of communication and interpersonal skills in the care and Management of these patients in the curriculum (Varhellan et, al. 1997). Lack of observational instruments to effectively evaluate the interactive nature of patient’s communication especially with reference to reliability and validity is also a barrier in care for such patients. Cognitive impairments pose a serious barrier on the reliability of nurse’s assessments of such patients (Phillips, 1993). The cognitive impairment that contributes to unreliable assessment of patients includes those related to comprehension, communicating, vision and hearing (Hines, 2000).

The Role of NVC

Use of non-verbal communication skills (NVC) to improve care has been recommended for cognitively impaired patients. A study outlining a health care professionals’ diagnosis of altered non-verbal communication and a new wellness diagnoses for enhanced non-verbal communication with detailed discussion on use of NVC with people with comprehension difficulties stresses on the fact that nurses play an important role in enhancing the non-verbal skills of the patient to help them communicate (Phillips, 1993). An assessment instrument, called, the Resident Assessment Instrument/Minimum Data Set (RAI/MDS) with a self incorporated MDS Cognitive Performance Scale (CPS) has been evaluated recently and has been found to contribute to the improvement of quality of nurse care of the cognitively impaired (,1998). Another instrument consisting of a single sheet of paper with the human body pictured from the front and from the back for the observation of touch and nurse-patient interactions has been developed recently (Routasalo, 1996).The non-verbal communication in such settings includes patient-directed eye gaze, affirmative head nod, smiling, learning forward, touch and instrumental touch (Wilma, 1999). It has been observed that these non-verbal communications have as tremendous impact on the patient’s well-being and comfort.  The nurses seem to eye gaze, head nod and smile to establish a good relationship.

Touching is a form of communication that is so important in nursing practice. The importance of improving communication by touch has been documented elucidating the importance of touch as an integral aspect of care, with the language of touch including tactile symbols of duration, location, action, intensity, frequency and sensation (Vortherms, 1991). A content analysis of the data in a recent study with 25 patients and 30 nurses interviewed using a semi structured schedule has shown that the patients experience touching by nurses as gentle, comforting and important. Touching induces a good relationship between nurses and their patients (Isola, 1996). Such a caring touch has been classified as affectional, functional and protective. An examination of touch between health care professionals’ and patients (McCann et. al, 1993) has shown that most touch interactions in a care of the elderly are instrumental in nature and expressive touches are usually given to body extremities like the forehead, arms and the legs. There cannot be an universal approach to employ non verbal communication like touch because of the fact that some  patients enjoy contact, some avoid contact, some are aggressive, some show only slight reaction and some patients do not react at all.   

The nurse should be able to perceive the expressions of the patient and also the patient’s perceptions of nurse’s interactions to provide maximum comfort. A study to elucidate patient’s perception of the use of touch and space by nursing staff that is critical in all aspects of patient care has shown that staff and patients’ perceptions of space and touch interactions are similar. Age and gender have been shown to influence these perceptions .A recent study has elucidated that a detailed coding of facial activity of the patients can provide an understanding of biological, behavioural, cognitive, and social parameters (McCallion 1999).The distance between the patient and the nurse, posture and position, utterance time, the direction of a nursing person’s face to the patient, facial expression, head nodding, gestures, and the self-contact behavior of a nurse during interaction with a patient are important variables of this non verbal communication process (Yoshiko, 2006).


A recent study to elucidate the implications of nurse researchers consciously using non-verbal communication to supplement verbal information has suggested the use of triangulation methodology of research to improve the validity of data obtained and the credibility of the findings (Begley, 1996).Communication problems seem to erode health care professional’s commitment to care (Nicola, 1995).Cognitive impairments and low health literacy pose a serious barrier on the reliability of patient assessments. Hence, there is a need for training the nurses on communication skills with reference to cognitive impairments and designing awareness programs for such patients towards better nurse care.



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