Use of the levels of cognitive functioning assessment scale (LOCFAS) by acute care nurses

Abstract

W ITH MORE than 1.5 million traumatic brain-injured (TBI) persons hospitalized annually for extended periods, nurses in acute care settings have the opportunity to make a difference in the rehabilitation of these patients' cognitive functioning (National Institute of Neurological and Communicative Disorder and Stroke, 1989). Although nurses are at the bedsides of patients with brain injuries and have the greatest opportunity for ongoing direct observation, nurses generally do not assess the cognitive level of these patients in the acute care setting. The data routinely collected as the basis for nursing care provide the necessary baseline to make such an assessment, but nurses who are not rehabilitative specialists may not know how to interpret these data to make a cognitive level diagnosis. The assessment of cognitive functioning for rehabilitation programming is more routinely done by neuropsychologists. For this type of evaluation to be administered, the patient must be able to comprehend, cooperate, and participate. Many weeks may elapse after trauma before the patient reaches this level. Because early intervention provides greater success for the patient's achieving maximum potential than later intervention, nurses caring for the TBI patient at an early stage of recovery are in a position to evaluate the patient's level of cognitive functioning and initiate rehabilitative measures before the patient is at the level appropriate for a neuropsychological evaluation (Hagen, 1982; Miller, 1984). The Levels of Cognitive Functioning Assessment Scale (LOCFAS) was developed from the Rancho Los Amigos Levels by author Jeanne Flannery using only Levels I through V of the eight original levels (Malkmus, Booth, & Kodimer, 1980). These selected levels include behaviors more commonly seen in the earliest stages of recovery, when the TBI patient is more likely to be in an inpatient acute care setting. For example, a Level I patient is in the deepest possible stage of coma. Six behaviors are assessed in the LOCFAS for this level and include items such as unresponsive to auditory, tactile, and painful stimuli. In contrast, a Level V patient is no longer comatose but remains disoriented to time and place. The patient can respond to simple commands but is unable to learn new tasks. Ten behaviors are included at this level to assess the TBI patient. For more detailed information or a copy of the instrument, please contact Dr. Jeanne Flannery. On the LOCFAS, a grid beside each behavior allows the nurse simply to make a check to indicate the presence of that behavior. Once completed, a summary grid allows the nurse to designate the cognitive level in which most behaviors were observed. The outcome shows the patient's maximum capacity at the time of each observation. Repeated use of the instrument also provides a common interdisciplinary language to describe a patient's progress in recovery. More important, by identifying the patient's current level of cognitive functioning, the tool can serve as a basis for the development of an appropriate plan of care to facilitate cognitive recovery. Initial psychometric data with the LOCFAS was reported by Flannery (1993). Construct and content validity were established by expert opinion. Three reliability studies were conducted using five written vignettes developed to represent each of the five LOCFAS levels. Interrater reliability, with raters experienced in assessing cognitive functioning for care-planning purposes, was supported with high agreement among cognitive levels (coefficient kappa = 1.00) and individual items (M coefficient kappa = .871). A second interrater re-